Discharge Against Medical Advice From the Tamale Teaching Hospital: Who Is Involved, the Prevalence and Departmental Differences

Discharge Against Medical Advice From the Tamale Teaching Hospital: Who Is Involved, the Prevalence and Departmental Differences | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Discharge Against Medical Advice From the Tamale Teaching Hospital: Who Is Involved, the Prevalence and Departmental Differences David Akagwire, Esther Terkour Padi, Vivian Kapio Abem This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6761858/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Discharge Against Medical Advice (DAMA) is a phenomenon where patients seek to terminate treatment against the advice of healthcare giver. Globally, DAMA represents a complex issue within healthcare systems, posing challenges to patients and healthcare providers. Generally, DAMA patients are at a higher risk for complications, re-admissions, increased healthcare costs, disability, longer rehabilitation and higher mortality. They are potentially a source of disease spread in communities and public. This study aimed to characterise the DAMA patients from a major referral facility, its prevalence at the hospital and departmental level. A retrospective descriptive cross-sectional design using quantitative method. Secondary data of 941 DAMA patients between December 1, 2020, to June 31, 2023, were extracted. DAMA patients (n = 941) showed an overall hospital prevalence rate of 1.75%. Accident and Emergency had a prevalence of 3.26%, followed by a prevalence rate of 2.25% at the Medicine and Therapeutics department. The polyclinic department recorded a prevalence rate of 1.72%, then the Department of Surgery followed closely with a prevalence rate of 1.54%. A low prevalence rate of 0.86% was obtained at the Department of Obstetrics and Gynecology while the paediatric department closely followed with a lower prevalence rate of 0.80. The dental department recorded no case. The majority of cases were male, 667 (70.88%). The majority of the patients; 650 (69.08%) were in the economically productive age group (between the ages of 20 to 61 years). Furthermore, 278 (29.54%) of patients had no form of formal education while 397 (42.19%) patients had some level of formal education. The majority 573 (60.89%) of patients who took DAMA had no form of health insurance. In addition, 144 (15.30%) of the patients were single while 241 (25.61%) were identified as married. Also, 506 (53.77%) of the patients belonged to the Islamic religion, 203 (21.57%) Christian and 16 (1.70%) of the patients practised African traditional religion. As many as 289 (30.71%) had no record of their employment status. Employed and unemployed had a total of 232 (24.65%) and 215 (22.84%) respectively. The hospital will utilize this knowledge to empower and encourage the records department of TTH to encourage its staff to endeavour to ensure complete data of the patient to be taken to further enable full analysis in future studies. Discharge against medical advice leave against medical advice Against medical advice Figures Figure 1 Figure 2 INTRODUCTION Discharge against medical advice (DAMA) refers to patients leaving the hospital against the advice of their medical health provider before treatment is completed. In other words, the situation where a patient who has been admitted to the hospital wishes to leave against the attending clinician's advice or where a patient chooses to leave the hospital before the treating physician has recommended discharge is referred to as discharge against medical advice (DAMA) or leave against medical advice (LAMA) or Against-medical-advice (AMA) discharges (Alfandre et al., 2017; Hasan et al., 2019). Estimates indicate DAMA occurs for around 2% of all hospitalizations, however, rates as high as 20% have been reported from specific institutions (Alfandre, 2009; Southern et al., 2007). Patients discharged against medical advice are at substantially increased risks of re-admission and mortality compared to those discharged regularly (Aliyu, 2002; Jerrard, 2016). DAMA is an important, yet understudied aspect of the healthcare system, particularly in African populations (Abuzeyad et al., 2021; Ekwedigwe et al., 2020). DAMA results in increased mortality, increased readmission rates, and higher healthcare costs all over the world (Abuzeyad et al., 2021; Ekwedigwe et al., 2020). According to available studies, DAMA has varying rates and causes based on the illness or condition, geographical area, and kind of treatment the health system provides (Albayati et al., 2021; GELPERIN, 1959; Hasan et al., 2019; Kraut et al., 2013; Noohi et al., 2013; Pasay-An et al., 2022; WILMER, 1955). It is a phenomenon that is not uncommon with an incidence rate that ranges between 0.8% and 2.2% of discharges from different teaching and tertiary care hospitals worldwide (Alfandre et al., 2017; Bartley, 2014; Fiscella et al., 2007; Kraut et al., 2013; Pasay-An et al., 2022). The phenomenon is even more a significant problem in emergency departments (EDs) across various health facilities (Abuzeyad et al., 2021; Alkahtani & Shujaa, 2021; Brenner et al., 2016; Ekwedigwe et al., 2020; Jerrard & Chasm, 2011; Lee et al., 2016; Noohi et al., 2013; Puri Singh et al., 2016; Sayed et al., 2016). In the United States each year, roughly 500,000 people, or 1-2 per cent of all hospital discharges, are classified as DAMA. (Abuzeyad et al., 2021; Lee et al., 2016; Sayed et al., 2016). This problem is not limited to the United States, a prior UK study discovered that 0.73 per cent of ED patients took DAMA and that 3% did not wait to be seen at all. DAMA has been linked to negative health outcomes and poor health service usage results when compared to those with scheduled discharges. These consequences include lower follow-up appointment attendance rates and greater rates of readmission, mortality, and recurrent DAMA episodes (Albayati et al., 2021; Ekwedigwe et al., 2020; Paul et al., 2019; Southern et al., 2012). In retrospective matched cohort research in 2011 with 656 patients, Choi et al. discovered that patients who left with DAMA had a 12-fold increased risk of readmission relative to the non-DAMA group. Additionally, they discovered that the 12-month all-cause mortality was higher in the DAMA group (6.7 per cent vs. 2.4 per cent, p = 0.01) (Choi et al., 2011; Lee et al., 2016). These higher death rates, readmission rates to hospitals and the anticipated total costs of DAMA on the healthcare system, undoubtedly impose a huge economic burden on the patient and government (Albayati et al., 2021; Alfandre, 2013; Edmunds et al., 2012). Meanwhile, the treating physicians may find it difficult to keep their oath to act in the patient's best interest and honour their preferences. This issue has a significant impact on both patients and physicians alike (Alfandre, 2013; Harel et al., 2016; Jeremiah et al., 1995; Levy et al., 2012; Pytell & Rastegar, 2018). A study conducted in 2012 by the Healthcare Cost and Utilization Project found that DAMA increased by 41% between 1997 and 2011 (Pfuntner et al., 2011). Studies conducted at numerous tertiary care facilities in low- and middle-income nations indicate that DAMA rates were far higher than those stated in high-income countries (Albayati et al., 2021; Alfandre, 2013). Many such studies from lower and middle-income countries report a prevalence rate of about 2.4% to as high as 25.8% (Alfandre, 2013; Alkahtani & Shujaa, 2021; Mensah, 2020). Due to the disease process and insufficient treatment, these patients frequently have severe illness at the time of self-discharge, which raises the possibility of death or the need for readmission (Baptist et al., 2007; Choi et al., 2011; Hwang et al., 2003; Lee et al., 2016; Levy et al., 2012). In Western countries, individuals admitted for mental health illnesses, substance misuse, as well as Human Immunodeficiency Virus positive (HIV) cases are most prone to encounter a DAMA incident (Baptist et al., 2007; Gerace et al., 1995; J. et al., 2012; Palepu et al., n.d.; Porter et al., 2012; Senior & Kibbee, 1986; Simon et al., 2020). Among HIV-infected patients, the rates of DAMA discharge range from 10% to 30% (Giordano et al., 2009; Southern et al., 2012; Torian & Wiewel, 2011). DAMA is predicted by patient-related factors such as younger age, male sex, low socioeconomic level, lack of insurance, and history of substance misuse in low-middle-income countries (Alfandre, 2013; Howard & Holmshaw, 2010; Lekas et al., 2016). Some studies also suggest that poor socioeconomic standing (low income and poor insurance status) principally explains DAMA (Abbani et al., 2023; Alkahtani & Shujaa, 2021; Puri Singh et al., 2016; Spooner et al., 2017; Yusuf et al., 2017). In recent times, particularly in Ghana and the entire African Sub-region, faith-based healing is well-advertised and is likely accounting for more numbers of patients seeking DAMA although no current objective research has been done on this subject matter (Bayor & Kojo Korsah, 2023; Gk & Pi, 2013; Mensah, 2020). Statement of the Problem According to the data available on the DAMA phenomenon, the proportion of DAMA patients makes up a very minor portion of all hospital discharges (Alfandre, 2018; Spooner et al., 2017). These are however significant since DAMA patients typically experience worse medical and surgical outcomes (Alfandre et al., 2017; Southern et al., 2012). The poor potential outcomes include but are not amputations, disfiguring scars, high readmission and death rates (Albayati et al., 2021; Ekwedigwe et al., 2020; Kavanagh et al., 2020). DAMA cases are also a high potential source of disease spread in the community. They are a potential source of both disease and treatment resistance and as such of a public health concern worldwide (Alfandre, 2018; Brenner et al., 2016; Holmes et al., 2021; Kavanagh et al., 2020; Pasay-An et al., 2022; Trépanier et al., 2023). Their long-term ill state tends to add to the patient burden and load for health workers and healthcare facilities (Albayati et al., 2021; Noohi et al., 2013). Most DAMA cases are a drain on the national economy since their ill state does not permit them to contribute meaningfully to the economy and long treatments increase direct healthcare costs in the country (Alagappan et al., 2023; Pasay-An et al., 2022). Global and sub-regional trends over the past years are readily not available but estimates put DAMA rates between 1% to 2% and it is steadily growing fast, especially in sub-Sahara Africa and the Middle East (Akinbodewa et al., 2016; Alidoust & Yahyavi, 2022; Mensah, 2020; Mohseni et al., 2015). Many facilities and departments such as the Orthopedics and Trauma department and Emergency department report higher rates (25.9%) (B.M. et al., 2015; M.E. et al., 2014; Menendez et al., 2015). DAMA rates are also significantly higher in patients with chronic conditions such as hypertension, diabetes mellitus, sexual weakness, psychiatric patients, substance abuse patients, and HIV-positive patients. These patients are usually managed over long periods and rarely get cured medically (Aljuhani, 2022; Howard & Holmshaw, 2010; Molina-Mula et al., 2018; Muzyk et al., 2019; Spooner et al., 2017; Torian & Wiewel, 2011). The researcher’s observations and accounts from health staff at the A&E, orthopaedic, neurosurgical, and medical departments especially show that many DAMA patients come back to the hospital in a worse state and are saved through more radical procedures and expensive medications that scar and further improvise these patients for life. DAMA also continues to wane down the morale and motivation of health personnel at the various departments. They see daily their best efforts go down the drain when patients request DAMA and derail their treatment plans (Jimoh et al., 2015; Molina-Mula et al., 2018; Muzyk et al., 2019). There has been little research done on the DAMA phenomenon in Ghana and where done, it is usually case or department-based. The Tamale Teaching Hospital is currently the main and biggest health facility in the Northern part of Ghana which serves a little over 5.8 million people (Ghana Statistical Service, 2021). This study will yield further insight into the DAMA phenomena for a wide area and varied groups of people. The proposed recommendations when implemented will have far-reaching impacts on many lives across a wide geographical area. Also, the study findings will contribute to the body of knowledge already available on the prevalence of DAMA in Ghana and help give evidence for the development of interventions aimed at lowering the level of DAMA in Ghana, Africa, and the world at large. METHODOLOGY Study Area: Tamale Teaching Hospital Tamale Teaching Hospital is within Ghana's Northern Region's Tamale Metropolis. Tamale is the sole metropolis in the north and one of the six (6) Metropolitan Assemblies in the nation. Tamale also doubles as both the Metropolitan and Northern Regional capitals. The Republic of Ghana's Constitution's legislative instrument, L.I. 2068, established the Tamale Metropolitan Area. Part of the 16 Metropolitan, Municipal, and District Assemblies (MMDAs) in the Northern Region, Ghana. Tamale is the capital of the Metropolis and it lies between latitudes 9.16° and 9.34° North and longitudes 00.36°and 00.57 west, with an estimated land size of 731 square kilometres according to the 2021 Population and Housing Census (PHC) (2021 PHC Report). Located in the nation's Savannah Woodland Region, the Metropolis borders the to the northwest, the Mion District to the east, the South Gonja, the South West, and the East Gonja. The Tamale Metropolis' population was estimated by the Population and Housing Census (PHC) of 2021 to be 374,744 which is urban. It had 189,693 (50.6 per cent) females and 185,051 (49.4%) males. (Ghana Statistical Service, 2022; Ghana Statistical Services., 2020). According to the 2021 Population and Housing Census, the population of the Metropolis is 223,252 representing 9.4 percent of the region’s population. Eighty-eight per cent of the population lives in urban regions, while the remaining percentage is in rural areas (19.1 per cent). In terms of ethnicity, The Dagomba people are the original inhabitants of the Metropolis, however, it is now home to a variety of ethnic and tribal groups. Dagombas make up more than 80% of the population of the Metropolis. The Gonja, Mamprusi, Nanumba, Konkomba, Asantes, Ewes, Hausa, and a few other minorities are some more tribal groupings. The Metropolis needs intertribal collaboration for peace and development, which makes this composition crucial. The major healthcare provider within the Metropolis is the public sector, whose services are augmented by several private clinics, pharmacies, and over-the-counter chemical sellers. The Tamale Teaching Hospital (TTH), Tamale Central/Regional Hospital (TCH), and Tamale West Hospital (TWH) are the main public health hospitals in the Metropolis. However, the indigenes' proximity to TTH has caused a further impact on health-seeking behaviour in that, there is an easy spread of disinformation and misinformation about the hospital. this spread of news rightly or wrongly is usually not done with malice intended but is mostly exaggerated with half-truths and untruths (Kanton et al., 2023; Lekuu & Yidana, 2023). Many people within the metropolis have the perception of dying when asked to seek healthcare at TTH and will generally come to TTH as the least lender of the resort. This behaviour leads many to come to TTH in a very bad state and when they die from the complications resulting from the delay, it further feeds the narrative of people dying at the hospital (Bayor & Kojo Korsah, 2023; Kanton et al., 2023; Lekuu & Yidana, 2023; Mensah, 2020). The northern part of the Ghana in particular has a very poor road and transportation networks. Its population is the poorest in the country, so many delays in seeking healthcare due to financial constraints and difficulty getting to the facility. The above reasons make the hospital to usually receive cases already with complications and very bad state. These cases with poor prognosis at arrival after dying leave very emotional relatives who used their ‘last penny’ to get to TTH with the hope of a cure. These relatives in telling their stories are mostly anything but objective. These stories go a long way to lead more patients with avoidable death conditions to report late after wasting most of their time visiting other sources of healing before they are brought to TTH in a state where little to nothing can be done to serve their lives. (Ghana Statistical Service, 2014; Kanton et al., 2023; Lekuu & Yidana, 2023; Lioce et al., 2020; Mensah, 2020; Mohammed et al., 2022; Nuhu, 2016). The current population of the five (5) regions is approximated at 5.8 million (Ghana Statistical Service, 2021). The hospital also serves most parts of, the northern parts of Oti, Volta, and Bone East Regions with an approximate population of about 3.6 million (Ghana Statistical Service, 2022; Lekuu & Yidana, 2023). There is evidence that people from the Southern Regions, mainly Greater Accra and Greater Kumasi areas also visit TTH for healthcare services due to the low cost of services compared to the other tertiary facilities in the country (DOSOO et al., 2020; GHS, 2017). In light of its medical tourism potential, it also manages cases from some West African neighbours, mainly Burkina Faso, Togo, Benin, and Sierra Leone (DOSOO et al., 2020). The hospital is located about two (2) kilometres southeast of Tamale, the capital of the Northern Region, and collaborates with the University for Development Studies (UDS), Tamale campus to offer undergraduate and graduate programs in Medicine, Nursing, and Nutrition amongst others. It was the third teaching hospital opened in Ghana after the Korle Bu Teaching Hospital and the Komfo Anokye Teaching Hospital CITATION Min06 \l 1033 (Ministry of Health, 2006) . Justification for Choice of Study Area Tamale Teaching Hospital is currently the main and biggest referral centre in the northern part of Ghana. The hospital receives referrals from all the regional hospitals and other health facilities in the Northern, Savannah, North East, Upper East and Upper West, Oti, Volta, and Bono East Regions with a current population of over 5.8 million according to Ghana 2021 population and housing census (Ghana Statistical Service, 2021, 2022). From the research's observations, TTH is a complex mix of various medical and surgery specialties which most patients find cumbersome to navigate around to attain health care and this easily gets patients and relatives frustrated with the system. TTH has also gained a bad reportage and reputation, especially among the locals of the Tamale Metropolis due to the many systemic and operational difficulties within the facility leading to many patients quickly and eagerly seeking DAMA. The study in this facility will give an insight into the DAMA phenomena for a wide group of the population over a large geographical area and the solutions proposed when implemented will have far-reaching impacts on many lives. Study Design A retrospective descriptive cross-sectional design was employed in this study. The research used quantitative method (Rezigalla, 2020; Somasundaran, 2022; Spector, 2019; Srikanth & Doddamani, 2013; Thiese, 2014; Tranfield et al., 2003). Study population The study population involved all patients who were admitted to the Tamale Teaching Hospital when the electronic folder (efolder) system known as the (Light-wave Hospital Information Management System (LHIMS) was introduced. Who requested and were granted DAMA from 1 st December 2020 to 30 th June 2023. This is irrespective of any particular parameter. They just needed to be patients who requested and were granted DAMA during the period of study. Inclusion criteria All entries included in the study were patients managed at TTH between 1 st December 2020 to 30th June 2023 and the entry should also be correctly filled on the LHIMS to have requested and granted DAMA. DAMA is a distinct category that patients are electronically placed in before they leave the hospital by the discharging physician. A list of all patients who took DAMA during the study period was generated and their records were extracted. All patients who left TTH based on DAMA have a signed DAMA letter that is vetted and approved by the discharging doctor. Exclusion criteria An entry was excluded from the study if patient documentation was not correctly filled or there was no proper proof by documentation of DAMA. Sampling Technique and Sample Size Determination All available records on patients who took DAMA during their management at TTH for the study period were used. Thus, a census was conducted for all individuals who sought DAMA during the research period. The study period saw about 53,342 people admitted to the Tamale Teaching Hospital through the various departments. Of the 53, 342 patients, 941 of them sought and were granted DAMA. All patients who took DAMA were included. Data source Secondary data from patients' records on the Light-wave Hospital Information Management System (LHIMS) of all those who took DAMA were extracted for the research. Indicators Assessed in the Study The main indicators in this study were the sociodemographic data, the prevalence and the different prevalence among the various départements. Data Collection Instruments A structured guide using Microsoft Excel was used for the extraction of data of DAMA patients information from their efolders. Data Collection Procedure The secondary data had components; sociodemographic characteristics (age, sex, marital status, religion, occupation, and insurance status) and the hospital admission record of the department were extracted into the already prepared structured guide on Microsoft Excel which was then cleaned after the extraction for further analyses in SPSS version 26. Data Quality Control To ensure the accuracy and validity of data collected in this study, the following measures were put in place: The structured guides that were used for data extraction and collection of the secondary data was designed in close reference with already published works. The research objectives set to answer the identified research questions also guided the design. Pretesting of all structured guides used in this study was done at the Accident and Emergency Department of TTH. Data was safely and securely stored on the researchers’ personal computers. No other persons had access to the data for possible distortion and manipulation. Before data analysis, data cleaning was undertaken to get a data set that was sufficiently consistent to permit precise analysis. Strengths of the Study The study was more precise since no sampling was done. The study was generally affordable and had limited information and recall bias. The study also covered a wide scope since the hospital receives patients from five (5) Regions. Informed consent There were no individual consent forms signed by DAMA patients since it was a retrospective study. Nonetheless, ethical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST). The ethical approval number CHRPE/AP/1021/23, dated 16 th November, 2023, enabled data extraction without individual consent from the already discharged patients. Data Analysis Plan Data was retrieved from LHIMS and collected into a Microsoft Excel application. It was then cleaned, coded, and imported into SPSS version 26. The SPSS software was further used to refine the data and to categorize it into continuous variables and discrete variables for easy analysis. In the univariate analysis that was done, descriptive statistics was calculated for the total study sample, and variables were summarized by their frequency distributions whereas numeric variables; continuous and discrete variables will be presented as percentiles. RESULTS Socio-demographic Characteristics of the Study Population The total number of patients admitted to the Tamale Teaching Hospital during the study period (1 st December 2020 to 30 June 2023) was 53,342 for all the departments. 941 of these patients requested and were granted DAMA resulting in a prevalence rate of 1.76%. The Socio-demographic Characteristics of these patients are presented in Table 1. The majority of DAMA patients were male 667 (70.88%) and 274 (29.11%) were female. Regarding the age, majority, 650 (69.08%) were in the economically productive age group (between the ages of 20 to 61 years) while 291 (30.92%) were in the dependent age group (patients between the ages of 0 to 20 and those above 60 years). During the extraction process, some 264 (28.06%) of the DAMA patients had missing records of educational status. However, those with no form of education were greater; 280 (29.54%). Patients with basic education were 181 (19.23%) while those with secondary education were 119 (12.65%). Patients with tertiary education 97 (10.31%). The majority of patients who took DAMA 573 (60.89%), had no form of health insurance to pay for their medical bills and thus had to pay out of pocket for all the services they received at the hospital. Quite a significant number, 368 (39.11%) were on the National Health Insurance Scheme (NHIS). No DAMA patient had any other form of Insurance. Furthermore, 144 (15.30%) patients who took DAMA documented that they were single while 241 (25.61%) were identified as married. However, 45 (4.78%) patients were widowed and 89 (9.46%) were divorced. Patients below the legal age of marriage in Ghana were captured as not applicable; less than 18 years; 237 (25.19%). On the other hand, 185 (19.66%) patients had missing records for marital status. A total of 216 DAMA patients’ records did not include their religious affiliation however, 203 (21.57%) were identified as Christians, 506 (53.77%) belonged to Islam and 16 (1.70%) practised African traditional region. Employment status was not applicable for patients below the legal age of 18 years in Ghana. However, it was noticed that some 16 and 17-year-olds were gainfully employed. A total of 205 (21.79%) were categorized as not applicable. The majority 289 (30.71%) had no records for employment so they were classified as missing. Employed and unemployed had a total of 232 (24.65%) and 215 (22.84%) respectively. The majority 642 (68.23%) of patients had no records for their Region of residence, however, the Northern Region recorded 151 (16.05%) patients, 75 (7.97%) patients were from the Upper East Region, 38 (4.04%) patients were from the Upper West Region, 19 (2.02%) patients were from the Savanna Region and 16 (1.70%) patients were from the North East Region. Finally, the occupation variable had farming as the single leading job with a total patient number of 97 (10.30%), closely followed by private artisanship workers with 93 (9.88%), then traders and drivers closely followed with 62 (6.59%) and 53 (5.63%) respectively. Civil servants were 36 (3.83%) and other occupations were 106 (11.26%). Table 1 below depicts the summary of the socio-demographic discussed above Table 1: Socio-demographic Characteristics of the Study Population (N=941) Variable Frequency Percentage Gender Male 667 70.88 Female 274 29.11 Age 0-10 108 11.48 11-20 148 15.73 21-30 263 27.95 31-40 182 19.34 41-50 162 17.22 51-60 43 4.57 61-70 26 2.76 71+ 9 0.96 Educational Status No Education 280 29.54 Basic 181 19.23 Secondary 119 12.65 Tertiary 97 10.31 Missing record 264 28.06 Insurance Status NHIS 368 39.11 Private 0 0 No Insurance 573 60.89 Marital Status Single 144 15.30 Married 241 25.61 Widowed 45 4.78 Divorced 89 9.46 Not applicable 237 25.19 Missing record 185 19.66 Religion Christianity 203 21.57 Islam 506 53.77 African Traditional Religion 16 1.70 Missing record 216 22.95 Employment Status Unemployed 215 22.84 Employed 232 24.65 Not applicable 205 21.79 Missing record 289 30.71 Region Northern 151 16.05 Savannah 19 2.02 North East 16 1.70 Upper East 75 7.97 Upper West 38 4.04 Missing record 642 68.23 Occupation Farming 97 10.30 Artisanship/Business/Private work 93 9.88 Trading 62 6.59 Driver 53 5.63 Civil Servant 36 3.83 Others 106 11.26 Not applicable 205 21.79 Missing record 289 30.71 Source: Field Survey 2023 Prevalence Rate of DAMA in various Departments at the Tamale Teaching Hospital There were varying prevalence rates within the seven (7) main departments at the Tamale Teaching Hospital. The overall prevalence rate of DAMA at TTH was 1.76%. The Accident and Emergency Department recorded the highest rate of 3.26% to 1.76% in the whole hospital followed by a 2.25% prevalence rate in the Medicine and Therapeutics department. The polyclinic department recorded prevalence a rate of 1.72%. The Department of Surgery recorded a prevalence rate of 1.54%. A prevalence rate of 0.86 was obtained at the Department of Obstetrics and Gynecology. The pediatric department closely followed with a rate of 0.80 while the dental department recorded no DAMA cases so a prevalence rate of 0. These prevalence rates are shown in Figure 1 below. The Accident and Emergency Department The Accident and Emergency department had a total of 11,727 admissions for the study period which made up 21.98% of the total admissions to the hospital. This department contributed 382 (40.59%) of the total number of participants in the research who took DAMA, shown in Figure 2 and Table 2. The department had a DAMA prevalence rate of 3.26%. Within the three (3) zones that make up the A&E department, the majority 234 (61.25%) of the patients who took DAMA were from the orange zone, followed by the yellow zone with 87 (22.77%) and was red zone with a total of 61 (15.97%). The Surgery Department Admissions of 10,851 were recorded in this department, making up 20.34% of the total admissions at TTH. The surgery department had a total of 167 DAMA patients shown in Figure 2 and Table 2. This represented 17.74% of all DAMA at TTH and a departmental prevalence rate of 1.54%. The sub-specialities within the department made different levels of contributions to the total number of DAMA cases. Two (2) sub-specialties made up more than 70% of the total DAMA cases in the department. Neurosurgical contributed 74 (44.31%) while Trauma and Orthopaedics with 43 (25.74%). The other seven (7) sub-specialities make up the rest of the less than 30%. General surgery recorded 17 (10.18%), pediatric surgery 9 (5.39%), ophthalmology 8 (4.79%), urology 6 (3.59%), Thoracic surgery 5(2.99%), plastic surgery 3 (1.80%) and that of Ear, Nose and Throat 2 (1.20%). The Paediatrics Department This department had a total of 10,205 making up 19.13% of total admissions to TTH. The total number of patients who were granted DAMA was 82 which made up 8.71% of the total DAMA cases from TTH. The total number of DAMA cases for the department is shown in Figure 2 above and Table 2. The department had a prevalence rate of 0.80%. this department has the Emergency sub-unit, which had a total of 17 (20.73%) DAMA patients, the children’s ward which had 65 (79.23%), and the Neonatal Intensive Care Unit (NICU) which had no DAMA granted. Medicine and Therapeutics Department The medical department had a total of 7,513 admissions over the study period which represented a total of 14.08% of the total admissions to TTH. The department had 169 cases take DAMA over the study period, as shown in Figure 2 and Table 2 below. This number accounted for 17.96% of all DAMA cases in the hospital. A prevalence rate of 2.25%. the department’s three (3) floors; M1 had a total of 41(24.26%) patients taking DAMA, M2 had 49 (28.99) DAMA and M3 made up the majority of 79 (46.75%). Obstetrics and Gynaecology Department Admissions were 9,122 over the two-and-a-half (2 ½) year period, which made up 17.10% of the total admissions at TTH. The O&G department saw a 78-patient discharged using DAMA, which contributed 8.29% to the total number of DAMA cases at TTH. The total number of DAMA cases for the department is shown in Figure 2 and Table 2. This department had a 0.86% prevalence rate, the Gynaecology wards contributed 61 (78.21%) to the total DAMA in the department while Obstetric wards made up 17 (21.79%) but the labour ward had no recorded DAMA cases The Polyclinic Department The Polyclinic Department contributed a total of 3,673 admissions to the hospital making up 6.89% of total admissions. The number of patients who were granted DAMA was 63 which made up 6.70% of the total DAMA cases recorded at TTH over the study period. The total number of DAMA cases for the department is shown in figure 2 and Table 2. A prevalence rate of 1.72% was recorded in this department. The Dentistry Department The dentistry department had a total of 251 admissions over the study period which represented 0.47% of total admissions to TTH. There was no DAMA case seen from this department as shown in Table 2. Table 1 : Summary of Departmental Information on DAMA at the TTH Department Frequency Percentage (%) Accident and Emergency Total Admissions 11,727 21.98 Patients who took DAMA 382 40.59 Prevalence of DAMA 3.26 Zones in the Department Yellow 87 22.77 Orange 234 61.25 Red 61 15.97 Surgery Admissions 10,851 20.34 Dama 167 17.74 Prevalence 1.54 Sub-Specialty Neurosurgery 74 44.31 Trauma And Orthopaedics 43 25.74 General Surgery 17 10.18 Pediatric Surgery 9 5.39 Ophthalmology 8 4.79 Urology 6 3.59 Thoracic Surgery 5 2.99 Plastic Surgery 3 1.80 Ear, Nose, and Throat 2 1.20 Paediatrics Total Admission 10,205 19.13 Patients who took DAMA 82 8.71 Prevalence of DAMA 0.80 Sub-units Emergency 17 20.73 Ward 65 79.23 NICU 0 0 Medicine and therapeutics Total Admissions 7,513 14.08 Patients who took DAMA 169 17.96 Prevalence of DAMA 2.25 Floors Medial 1 41 24.26 Medical 2 49 28.99 Medical 3 79 46.75 Obstetrics and Gynaecology Total Admissions 9,122 17.10 Patients who took DAMA 78 8.29 Prevalence of DAMA 0.86 Sub-unit Gynaecological ward 61 78.21 Obstetric ward 17 21.79 Labour ward 0 0 Polyclinic Total Admissions 3,673 6.89 Patients who took DAMA 63 6.70 Prevalence of DAMA 1.72 Dentistry Total Admissions 251 0.47 Patients who took DAMA 0 0 Prevalence of DAMA 0 Source: Field Survey, 2023 DISCUSSION Socio-demographic Characteristics of Study Population. The total number of patients admitted to TTH during the study period was 53,342 while 941 of these patients requested and were granted DAMA. This resulted in a DAMA prevalence rate of 1.76% for the study period. The prevalence is consistent with the global rate of between 0.07- 20% (Alfandre et al., 2017; Gk & Pi, 2013; Spooner et al., 2017). In a study conducted at the same hospital, TTH although just from one (1) department, the prevalence rate was 2.5% not far off what this study unearthed (Bayor & Kojo Korsah, 2023). These findings are also similar to other regional rates. In Nigeria, rates of 3.8% and 4.5% were obtained in two (2) studies conducted in Abuja, Nigeria (Gk & Pi, 2013; Yusuf et al., 2017). A study in the UK also unearthed a rate of 3% while one in the U.S.A. was 0.9% (Alagappan et al., 2023; Sayed et al., 2016; Spooner et al., 2017). These varying prevalence rates were generally impacted by the geographical and type of hospital at which the study was conducted (Alkahtani & Shujaa, 2021; Spooner et al., 2017). This prevalence rate of DAMA at TTH has very significant and grave consequences for patients especially but also for the hospital, the general health system, and the country as a whole. These number of patients are generally improvised since they are economically inactive during, the long duration of illness which directly affects their dependents if any, or burdens for their caregivers and relatives. The hospital generally loses money from the termination of their admissions, the hospital infrastructure and staff are also stressed since the majority of these DAMA cases will come back on admission usually in a worse state for management. Health services delivered to patients are generally subsidized by the government of Ghana. In the long term, the government spends more money to subsidize services for these patients. The majority of these patients seek multiple care from the same hospital or other health facilities after seeking further putting stress on the government and its other agencies such as the NHIS and the welfare service (Fenny et al., 2015; Mensah, 2020; Pasay-An et al., 2022). The analysis of the characteristics of the study group showed that the majority were male repenting a total of 667 (70.88%) and the other 274 (29.11%) were female. TTH serves an area where motorbikes and tricycles are the common means of transportation and are usually ridden by males with no helmets on. Accidents often occur leaving many injured. In many cases, which involve men, seek DAMA after initial assessment quickly (Abuzeyad et al., 2021; Sayed et al., 2016; Trépanier et al., 2023). A study at the TTH emergency department found that men usually have socioeconomic responsibilities of family upkeep and are more likely to avoid hospitalization to reduce the cost of health care (Bayor & Kojo Korsah, 2023). Females are also generally known to be more compliant with medical care and more concerned about their health. They will often need to be fully fit before discharge (Alkahtani & Shujaa, 2021; Bayor & Kojo Korsah, 2023; Jimoh et al., 2015; Mohseni et al., 2015; Noohi et al., 2013). These rates are also consistent with other studies done in Nigeria where males were 57.3% to 42.7% of females (Gk & Pi, 2013)and similar rates were also observed in other studies around the globe (Alfandre, 2018; Hasan et al., 2019; Pasay-An et al., 2022; Spooner et al., 2017; Yusuf et al., 2017). Similar results were also obtained from studies conducted at single departments and whole hospitals in Lebanon, Saudi, Nigeria, and the UK (Akinbodewa et al., 2016; Alagappan et al., 2023; Alkahtani & Shujaa, 2021; Trépanier et al., 2023; Yusuf et al., 2017). The northern sector of Ghana has many men as the solo breadwinners of their nuclei and extended families. Many men usually taking DAMA with its attended complications leave many of their families improvised and burdened. Regarding the age, majority, 650 (69.08%) were in the economically productive age group (between the ages of 21 to 60 years) while 291 (30.92%) were in the dependent age group (patients between the ages of 0 to 20 and those above 61 years). DAMA complications cause the majority of these economically active people to stay inactive over long periods which impacts their finances directly and broader impacts the gross domestic product of the country. Many of the DAMA patients 573 (60.89%) had no form of insurance and had to pay out of pocket. The group enrolled on the NHIS had to pay top-ups for most services rendered to them. However, NHIS makes a big difference in total health costs and many people appreciate this fact when they seek health without any form of insurance. Not surprisingly, private health insurance has full coverage for all services received and as such no patient with this kind of insurance took DAMA. Although many other factors lead to patients seeking DAMA, many are willing to forego any other reason and stay on admission till medically advised discharge so long as they are paying nothing out of pocket (Hwang et al., 2003; Sayah et al., 2014; Trépanier et al., 2023). Other studies done in the US also showed that patients with private insurance were less likely to seek DAMA compared to patients on MEDICARE or paying out of pocket (Albayati et al., 2021). These findings are consistent with other studies that cover the topic of insurance in DAMA patients as well (Hasan et al., 2019; Noohi et al., 2013). Many of these patients were already burdened with responsibilities as breadwinners of families and usually wanted to spend as little time and money at the hospital. Many families found in these poorest regions of the country are barely surviving and do not earn enough to afford a form of proper health insurance which many see as expansive and out of their reach. Education as a variable also saw 264 (28.06%) of the DAMA patients having missing records for educational status. Aside from those with missing records, those with no form of education were 280 (29.54%), followed by those with basic education 181 (19.23%) secondary education with 119 (12.65%) and tertiary education 97 (10.31%). Compared to another study done at the TTH A&E department, 85 (40.5%) had missing records and had fewer patients 55 (26.2%) being uneducated compared to educated patients of 70 (33.3%) (Bayor & Kojo Korsah, 2023). One can make an inference from observations that most patients with missing records on education most likely had no form of education. The records staff would usually skip this part during the registration process when responses are not forthcoming (Abbani et al., 2023; Maier et al., 2023; Mohammed et al., 2022). With this inference in mind, one can state that the majority of patients 544 (57.81%) who sought DAMA had no form of education. Moreso, in this part of the world where education is usually directly linked with good opportunities for jobs and a relatively good amount of wealth which enables them to afford health care compared to the rest of the general population (Abuzeyad et al., 2021; Alfandre, 2018; Alfandre et al., 2017; Alkahtani & Shujaa, 2021; Bayor & Kojo Korsah, 2023; Choi et al., 2011; Mohseni et al., 2015; Pytell & Rastegar, 2018; Sayed et al., 2016; Yong et al., 2013). Of the patients missing records for marital status 185 (19.66%), 241 (25.61%) were married, 89 (9.46%) were divorced while 237 (25.19%) of the patients below 18 years, the legal age for marriage in Ghana so were categorized as not applicable. Other research papers done in the subregion and globally varied greatly. This variable through lecture had less impact on a person’s decision to take DAMA or not (Abbani et al., 2023; Alfandre, 2018; Sayed et al., 2016). The majority 505 (53.77%) of DAMA patients identified as belonging to Islam while 203 (21.57%) identified as Christians. A few 16 (1.70%) of them identified as Traditionalist and as many as 216 (22.95%) patients had missing records for this variable. Findings were for the most part consistent with findings in a prior study done at TTH (Bayor & Kojo Korsah, 2023), however, findings variable in other studies that were done in other geographical locations across the globe (Sayed et al., 2016; Spooner et al., 2017; Trépanier et al., 2023). The local population living closer to the health facility are predominantly Muslim and as such the Islamic religious grouping contributes more to the statistics. The employment status unearthed 289 (30.71%) without records while 205 (21.79%) patients were below the age of 16 and were legally not allowed to be employed in Ghana so were categorized as not applicable. 232 (24.65%) patients were employed in occupations such as farming 97 (10.30%), artisanship 93 (9.88), trading 62 (6.59), drivers 53 (5.63%) and 36 (3.83%) civil servants while 215 (22.84%) were documented as unemployed. However, much inference cannot be made about the employment status due to such a large number of patients with no records. Other studies done in the sub-region also showed such close divide between employed and unemployed (Abbani et al., 2023; Bayor & Kojo Korsah, 2023; Yusuf et al., 2017). In the developed world, the data shows otherwise, the majority of DAMA patients are documented as unemployed (Sayed et al., 2016; Spooner et al., 2017; Trépanier et al., 2023). Prevalence Rate of DAMA in various Departments at the Tamale Teaching Hospital The hospital had a prevalence rate of 1.76%. Two (2) out of the seven (7) departments of the hospital recorded far higher prevalence rates. The Accident and Emergency Department and the Medicine and Therapeutics Department recorded 3.26% and 2.25% respectively. The A&E department not surprisingly, had the highest prevalence rate at the departmental level. This department is the first point of call for most cases and the data shows that most cases of DAMA do so while waiting to be moved to the wards of other departments. Most patients are most likely to seek DAMA at the point they are stable and awaiting trans out to the ward of other departments. These patients erroneously believe they are out of danger and at no risk of mortality. A similar result of 2.45% was obtained from a 2-year study done at the TTH A&E in 2021 (Bayor & Kojo Korsah, 2023). Other studies that were conducted at the A&E departments of other tertiary hospitals around the world also showed similar results (Bayor & Kojo Korsah, 2023; Ekwedigwe et al., 2020; Hasan et al., 2019). The medicine and therapeutic department also recorded a higher rate of prevalence 2.25% compared with the general prevalence rate of 1.76%. This may likely stem from the fact that, as a tertiary facility it receives referrals from hospitals all over a wide area. Many of the population generally have poor health-seeking behaviour and many reports for care late with avoidable complications and poor prognosis. They spend many more days on admission with little to no visible improvements in their condition such as stroke, congestive cardiac failure, and chronic liver and kidney diseases. These patients are therefore for likely to seek DAMA which accounts for the relatively higher prevalence rate compared to the whole hospital. Also, these patients suffering from chronic diseases are likely to want to try faith-based healing once the doctors counsel them on the need to manage their case with no definite cure then (Alfandre et al., 2017; Asampong et al., 2015; Lekuu & Yidana, 2023; Mensah, 2020; Nuhu, 2016). The Polyclinic and Surgery departments had prevalence rates that were much closer and similar to that of the general hospital prevalence rate of 1.75%. The prevalence rates were 1.72% and 1.54% respectively. The polyclinic usually attends to stable cases who make quick recovery within short periods and are more likely to be discharged formally. The surgery department mostly gets its admissions through the A&E department most of the patients who are likely to seek DAMA are likely to have done so at the A&E department before trans-outs are done to the surgery department wards (Brenner et al., 2016; Rughani et al., 2013; Spooner et al., 2017). The Obstetrics and Gynecology department had a low prevalence rate of 0.86% compared to the whole hospital's prevalence rate of 1.75%. The O&G department generally manages women in labour who come to delivery and will most likely not seek any DAMA. The few DAMA cases mostly resulted from terminal gynaecological cases such as cervical and ovarian cancers. Few were also cases under post-abortion care and these with complications. These groups of patients are usually uncomfortable in an open-ended hospital and as such always have a high potential to seek DAMA. They rightly or wrongly assume and feel people will get to know them and make them victims of social mockery (Alkahtani & Shujaa, 2021) The Paediatric department recorded a prevalence rate of 0.80% which was also far below the hospital’s prevalence rate of 1.76%. The paediatric department generally by law makes seeking DAMA for minors harder for relatives compared to DAMA for adults. This system helps encourage many to rescind their decision and not go through with the DAMA. Children’s medications, laboratory investigations and imaging are also generally cheaper and easier to get financial help from the social welfare department of the hospital. However, some few people will still tend to seek DAMA leading to such prevalence rates at the department. A study done in a paediatric ward at a university hospital in Port Harcourt Nigeria, yielded a prevalence rate of 3.8%(Alagappan et al., 2023; Gk & Pi, 2013) which was way higher than even the general hospital rate. Children at TTH paediatric department had NHIS which is essentially free to enrol for minors and some of the care received at the hospital. The dental department recorded no DAMA cases. The department mostly sees patients on an outpatient basis and even when admitted, just for a very short duration for a procedure after which patients are discharged to be followed up regularly at the outpatient clinic. The operations of this department lead to them rarely to never having patients seeking DAMA. There was no literature found on DAMA at the dental department and not surprising because is not mostly problem in this department. Their main issue is with patients self-discharging from their clinics and not showing up for regular reviews. Accident and Emergency Department The Accident and Emergency department had a total of 11,727 admissions for the study period which made up 21.98% of the total admissions to the hospital. Nonetheless, this department contributed 382 (40.59%) to the total DAMA cases recorded in the hospital. The department had a DAMA prevalence rate of 3.26% compared to the general of 1.75%. Most patients are often likely to seek DAMA at the department once they are stable and believe they are out of danger and at risk of mortality. Within the three (3) zones that make up the A&E department admissions, the majority 234 (61.25%) of the patients who took DAMA were from the orange zone, followed by the yellow zone with 87 (22.77%), and then the red zone with a total of 61 (15.97%). The red zone cases are usually critical cases that need more medical attention so many are less likely to seek DAMA. When compared to the other zones, the patients admitted to the yellow zone are frequently quite stable. When compared to other zones, they are typically released earlier for follow-up care in the outpatient clinic. However, patients admitted to the Orange Zone typically stay longer, which results in increased costs and additional expenses. The financial constraint is more likely to lead them to seek a DAMA since they are no longer critically ill after a few days of management. A similar result was attained in other studies across the globe done at the emergency departments of tertiary hospitals in Canada, Iran, Saudi Arabia and Nigeria (Abuzeyad et al., 2021; Alkahtani & Shujaa, 2021; Lee et al., 2016; Sayed et al., 2016; Trépanier et al., 2023). The Surgery Department Total admissions of 10,851 were recorded in this department which made up 20.34% of the total admissions at TTH. The department also contributed 167 (11.74%) to all DAMA cases in the hospital. The departmental prevalence rate of 1.54% mirrored closely to that of the hospital at 1.75%. The sub-specialities within the department made different levels of contributions to the total number of DAMA cases. Two (2) out of the nine (9) sub-specialities made up more than 70% of the total DAMA cases in this department, Neurosurgery sub-specialities contributed 74 (44.31%) while Trauma and Orthopaedics contributed 43 (25.74%). This is generally not surprising since the majority of DAMA causes were head injuries and fractures from road traffic accidents which are managed by these two (2) sub-specialities respectively. Road traffic accidents involving motorbike riders without crushing helmets are quite endemic in the areas served by the hospital. In other studies, done in the sub-region, the surgery department had similar results as this study unearthed. The common reason found in the literature for this DAMA prevalence rate was refusal of recommended surgery however the patients at TTH are in the habit of using financial constraints as a reason while concealing their actual reasons (B.M. et al., 2015; Jimoh et al., 2015; Trépanier et al., 2023). The other seven (7) sub-specialities made up the rest of less than 30% of the DAMA cases recorded over the study period. These other sub-specialties may have contributed less because most of their cases are acute and life-threatening. These patients also turn to see quick improvements and are less likely to seek DAMA. A patient with a cataract can have poor vision over the years and after a cataract surgery done by the ophthalmologist which usually takes less than an hour. The next day, the patch is removed and the patient has improved vision, this is so quick a result that there enough fewer patients seeking DAMA from these sub-specialities. Throughout literature from developed and developing countries, research done in tertiary facilities, the results obtained are not so different from the surgery department (Alfandre et al., 2017; Brenner et al., 2016; Paul et al., 2019; Rughani et al., 2013; Trépanier et al., 2023). The Paediatrics Department The Paediatrics Department had a total of 10,205 making up 19.13% of total admissions to TTH. The number of patients who were granted DAMA was 82 which made up 8.71% of the total DAMA cases from TTH. The paediatric department mandated by law makes seeking DAMA for minors harder for relatives compared to DAMA for adults. This system helps encourage many to rescind their decision and not go through with the DAMA. Children’s medications, laboratory investigations and imaging are also generally cheaper and easier to get financial help from the social welfare department of the hospital. A study conducted in a paediatric ward at a university hospital in Port Harcourt Nigeria, yielded a prevalence rate of 3.8%(Alagappan et al., 2023; Gk & Pi, 2013) which was way higher than even the hospital rate. This may be because many of the children in Ghana are enrolled on the NHIS. The NHIS is essentially free to enroll for minors and many of the children’s medications and laboratory investigations needed are covered at the hospital. The department has the Emergency sub-unit, which had a total of 17 (20.73%) DAMA patients. This unit is a short transition point for patients to be stabilized before moving to the main children's ward and may explain why a minority of the DAMA cases came from this unit. The children’s ward which had 65 (79.23%) DAMA cases. The unit is where patients are admitted till full recovery. The long duration of monitoring for children before discharge even after medical improvement compared to adults leads more relatives to seek DAMA. The last unit in the department is the Neonatal Intensive Care Unit (NICU). This unit had no DAMA granted and understandably so. The units take care of babies below the age of one month (from birth to 28 days old) and at this stage of life, many parents find it difficult to handle sick babies so are more likely to leave the baby at the unit when they even run out of funds than to seek DAMA. Much research done in paediatric departments in the sub-region also had similar findings. In one such study done in Abuja, Nigeria, there were no DAMA cases recorded at the NICU over the study period. A similar result was obtained in another study done in Saudi Arabia (Alkahtani & Shujaa, 2021; Gk & Pi, 2013; Kavanagh et al., 2020). The Medicine and Therapeutics Department The medical department had a total of 7,513 admissions over the study period which represented 14.08% of the total admissions to TTH. The department had 169 cases who sought and were granted DAMA over the study period. This number accounted for 17.96% of all DAMA cases in the hospital. A prevalence rate of 2.25% was seen in the department a higher prevalence rate compared to the hospital. As the only tertiary and referral facility in the northern part of Ghana, it receives referrals from hospitals all over a wide area. The inhabitants also have poor health-seeking behaviour and many reports for care late with avoidable complications and poor prognosis. They turn to spend many more days on admission with little to no visible improvements in conditions such as stroke, congestive cardiac failure, and chronic liver and kidney diseases. These patients are therefore more likely to seek DAMA which accounts for the relatively higher prevalence rate compared to the whole hospital. Also, these patients suffering from chronic diseases are likely to want to try faith-based healing once the doctors counsel them on the need to manage their case with no definite cure then (Alfandre et al., 2017; Asampong et al., 2015; Jacobowitz, 1974; Lekuu & Yidana, 2023; Mensah, 2020; Nuhu, 2016). The medical department has three (3) floors; named medical 1 (M1) which takes care of cardiovascular cases had a total of 41(24.26%) patients taking DAMA. On the second floor called medical 2 (M2) patients had 49 (28.99) DAMA cases. M2 typically cares for stroke and general neurological disease. The third and last floor, medical 3 (M3) takes care of gastroenterological cases such as chronic liver disease patients, diabetics and hypertensive. This floor contributed the majority of 79 (46.75%) of DAMA cases in the medical department. The M3 turn to manage chronically ill patients who usually do not get cured but many with the hope of getting fully cured will turn to other forms of healing. Currently, in Ghana, there are freely advertised faith-based healing and many herbal healings that rightly or wrongly ‘calm’ to cure these chronic diseases with any regulation and checks (Bayor & Kojo Korsah, 2023; Kunu & Philip Sunday, 2021; Mensah, 2020). Obstetrics and Gynaecology Department Admissions at the department were 9,122 over the two-and-a-half (2 ½) year period which made up 17.10% of the total admissions at TTH. The O&G department saw 78 patients discharged through DAMA which contributed 8.29% to the total number of DAMA cases at TTH. This had a low prevalence rate of 0.86% compared to 1.75% of the hospital. Understandably so, the O&G department generally manages women in labour who come to delivery and will most likely not seek DAMA since governmental subsidies make this department one of the cheapest to seek healthcare in the hospital and even compared to other tertiary facilities in the country (DOSOO et al., 2020). The few DAMA cases resulted from terminal gynaecological cases such as cervical and ovarian cancers, some were also from post-abortion care and its complications. These groups of patients are usually uncomfortable in an open-ended hospital and as such always have a high potential to seek DAMA. They rightly or wrongly assume and feel people will get to know them and make them victims of social mockery (Alkahtani & Shujaa, 2021). The Gynaecology wards contributed 61 (78.21%) to the total DAMA in the department. In comparison, Obstetric wards made up 17 (21.79%). Still, the labour ward had no recorded DAMA cases since many patients who delivered were discharged from the ward after the 24 hours of monitoring without further delays leaving no room for patients to seek DAMA. Polyclinic Department This department had a total of 3,673 making up 6.89% of total admissions to TTH. The number of patients who were granted DAMA was 63 which made up 6.70% of the total DAMA cases recorded at TTH over the study period. A prevalence rate of 1.72% was recorded in this department which was much closer and similar to that of the general hospital prevalence rate of 1.72% and 1.54% respectively. The polyclinic generally attends to relatively stable cases so are more likely not to see long admissions and therefore leave little room for them to seek DAMA therefore seeing similar prevalence rates. The surgery department mostly gets its admissions through the A&E department most of the patients who are likely to seek DAMA are likely to have done so at the A&E before trans-outs are done to the surgery department wards (Brenner et al., 2016; Rughani et al., 2013; Spooner et al., 2017) Dentistry Department The dentistry department had a total of 251 admissions over the study period which represented 0.47% of total admissions to TTH. This department usually attends to most of their cases on an outpatient basis so contributed less than 1% to the total admissions in the hospital. There was no DAMA case seen from this department since this department mostly sees patients on an outpatient basis and even when admitted, just for a short duration (usually less than 2 days). Most are discharged after a few hours of monitoring on the ward after the procedure and followed up regularly at the out-patient clinic so this department rarely to never will get patients seeking DAMA. Their main issue is with patients self-discharging from their clinics and not showing up for regular reviews. SUMMARY AND CONCLUSION Summary The study found that the prevalence rate of DAMA at TTH was 1.76%. It also found that the majority 71% of all DAMA patients were male with 29% female. The majority (69%) were economically productive age group while 31% of all DAMA cases were not. The majority 280 (29.54%) had no form of education,216 (42.4) had some form of education and 264 (28.06%) had no record of education. It was also noted that 573 (60.89%) had no form of health insurance. The study also showed that the Accident and Emergency Department, the Department of Medicine and Therapeutics, and the Surgery Department were the departments with the highest contributions to the DAMA patient numbers with 382 (40.59%), 169 (17.96%) and 167 (17.74%) respectively. The study also unearthed a higher intra-departmental prevalence rate than that of the hospital at the A&E department 3.26% and 2.25% at the Department of Medicine and Therapeutics. The other five (5) departments had lower prevalence rates compared to that of the hospital. Conclusion Discharge against medical advice is still a common issue that has an impact on hospital resources, the economy, and patient outcomes. Although a wide range of individuals are affected, those with particular traits and comorbidities appear to be more inclined to refuse medical advice and depart. While this issue has a variety of root causes, some universal approaches can be implemented to effectively mitigate patients' suffering discharge against medical advice, a structure designed to support and shield healthcare facilities and physicians in their efforts to preserve patients' health, particularly when they are faced with competing patients’ family interests. Limitations of the Study There is hardly any study without limitations and this study was no exception: In the first place, using data that has already been collected could not ensure the highest level of accuracy. Also, some variables that would have enriched the research were excluded because that data was not available on the patient records. These variables included the community and Region of residency and whether the patient came in as a referral from another hospital or not. Other variables had large numbers of patients with missing records that no meaningful or further analysis could be done. Information on the demographics collected at the records point may be wrongly inputted and such variables cannot be detected since the patients are not available for verification. Furthermore, the study was further limited by not including other ‘DAMA patients’ who self-discharge from follow-up clinics and reviews after formal medical discharge from in-patient care. These reviews are technically part of management but many fail to comply since they are mostly stable and not acutely ill. They do not officially inform the hospital of this discontinuation of care and are therefore a DAMA group that are overlooked. However, these limitations were not significant enough to affect the findings of the study. Abbreviations A&E Accident and Emergency AIDS Acquired Immune Deficiency Syndrome AMA Against Medical Advice DAMA Discharge Against Medical Advice ED Emergency Department FBH Faith-Based Healing FGDs Focused Group Discussions GDP Gross Domestic Product GHS Ghana Health Service GSS Ghana Statistical Service GMS Ghana Metrological Service ICU Intensive Care Unit HIV Human Immunodeficiency Virus LAMA Leave Against Medical Advice LMIC Low- and Middle-income countries MMDAs Metropolitan Municipal District Assemblies MOH Ministry of Health NICU Neonatal Intensive Care Unit OPD Out-Patient Department RTA Road Traffic Accident TTH Tamale Teaching Hospital UK United Kingdom USA United States of America WHO World Health Organisation Declarations Ethics approval and consent to participate First off, written permission was obtained from the TTH Research Directorate with reference number TTH/R&D/SR/298 dated 16 th October 2023. This permission letter was used to apply for ethical approval for the study and also copied to the departments of the hospital to enable the research work to proceed. Ethical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST) before data collection. The ethical approval number CHRPE/AP/1021/23 dated 16 th November, 2023. This ethical approval was valid for a year, between 16 th November, 2023 to 15 th November, 2024. The research adhered to the Declaration of Helsinki on which bases ethical approval was given. Find in supplementary file 1. Additionally, the permission letter from TTH R&D and the ethical approval was copied to the various departments of TTH to inform the departmental management. Anonymity was achieved by removing the names and hospital identification numbers of the patients during the cleaning of the data for analysis. They were initially included to enable easy identification of patients for cross checking of the data and for the second part of the study which is not reported here. This were phone call in-depth interview to ensure DAMA patients or relatives were actually interviewed. Informed consent There were no individual consent forms signed by DAMA patients since it was a retrospective study. Nonetheless, ethical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST). The ethical approval number CHRPE/AP/1021/23, dated 16 th November, 2023, enabled data extraction without individual consent from the already discharged patients. Consent for publication Not applicable Availability of data and materials The data that support the findings of this study are available from Tamale Teaching Hospital patient eFolders but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the research department of Tamale Teaching Hospital. Competing interests The authors declare that they have no competing interests Funding It was funded by the corresponding author Authors' contributions Dr. Akagwire David (MD) – conceptualisation, data collecting, analysis, administration, writing – original draft (lead) Esther Terkour Padi –, writing – original draft, writing – review and editing Vivian Kapio Abem (PhD)– Supervision, writing - review and editing Acknowledgements I want to thank the management and staff of Tamale Teaching Hospital for their generous support throughout this research. My special thanks go to the head and staff of the records department for helping me with the extraction of the secondary data especially. God bless you all. References Abbani, A. Y., Sawangdee, Y., Omisakin, O. A., & Maretalinia, M. (2023). Socio-Demographic Determinants of Non-Utilisation of Antenatal Care Services by Women in the Northern Region of Nigeria. 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Internal Medicine Journal , 43 (7), 798–802. https://doi.org/https://doi.org/10.1111/imj.12109 Yusuf, M. B., Ogunlusi, J. D., Popoola, S. O., Ogunlayi, S. O., Babalola, W. O., & Oluwadiya, K. S. (2017). Self-discharge against medical advice from tertiary health institution: A call for concern. The Nigerian Postgraduate Medical Journal , 24 (3). https://doi.org/10.4103/npmj.npmj_88_17 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6761858","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":467301895,"identity":"8a2e2d02-1ed6-44ee-bebd-069c1f9926cc","order_by":0,"name":"David Akagwire","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACHhBhAMQHmA8ASQkZUrSwJYC08BCpBQQO8Big8HEC/p7Dj1/zFNyT4zt+5vOrGzUWPAzsh49uwKdF4mybmTWPQbGx5JncbdY5x4AO40lLu4HXmvMMZsY5BgmJG27wbjPOYQNqkeAxw6tF/jz7N5CW+g03eJ4Z5/wjQovB2R7jx0AtCQY3eJgf57YRocXwzJky5j8GCYYzz6SZMef2SfCwEfKL3Jn0zR9n/EmQ5zt++PHnnG91cvzsh4/h9z4DA5sECoONgHIQYP6AzhgFo2AUjIJRgAIAXGZImIaXmxQAAAAASUVORK5CYII=","orcid":"","institution":"Tamale Teaching hospital","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Akagwire","suffix":""},{"id":467301896,"identity":"287cd966-2bed-4cbb-9e6d-27f268b73e19","order_by":1,"name":"Esther Terkour Padi","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Esther","middleName":"Terkour","lastName":"Padi","suffix":""},{"id":467301897,"identity":"9014a84a-bc1f-4904-a57d-2cc6f511cfb9","order_by":2,"name":"Vivian Kapio Abem","email":"","orcid":"","institution":"University for Development studies","correspondingAuthor":false,"prefix":"","firstName":"Vivian","middleName":"Kapio","lastName":"Abem","suffix":""}],"badges":[],"createdAt":"2025-05-27 18:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6761858/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6761858/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84304900,"identity":"cfac46e0-2808-4a9b-9f17-5faee2e79fc5","added_by":"auto","created_at":"2025-06-10 11:23:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":10181,"visible":true,"origin":"","legend":"\u003cp\u003eIntra-departmental prevalence rates\u003c/p\u003e\n\u003cp\u003eSource: Field Survey 2023\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6761858/v1/45af5ab0d015252d0ae846d3.png"},{"id":84304752,"identity":"efac963f-29e8-479c-b832-b9e6447899d7","added_by":"auto","created_at":"2025-06-10 11:23:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":10598,"visible":true,"origin":"","legend":"\u003cp\u003eNumber of DAMA patients per Departments\u003c/p\u003e\n\u003cp\u003eSource: Field Survey 2023\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6761858/v1/07e2fecad7e1713963891111.png"},{"id":107133160,"identity":"cec990fe-222e-45b7-a2c7-e55ac13d1880","added_by":"auto","created_at":"2026-04-17 07:28:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1096782,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6761858/v1/0e473dab-8eae-47a6-bc89-0fea4cf01bd8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eDischarge Against Medical Advice From the Tamale Teaching Hospital: Who Is Involved, the Prevalence and Departmental Differences\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDischarge against medical advice (DAMA) refers to patients leaving the hospital against the advice of their medical health provider before treatment is completed.\u0026nbsp;In other words, the situation where a patient who has been admitted to the hospital wishes to leave against the attending clinician\u0026apos;s advice or\u0026nbsp;where a patient chooses to leave the hospital before the treating physician has recommended discharge is referred to as discharge against medical advice (DAMA) or leave against medical advice (LAMA) or Against-medical-advice (AMA) discharges (Alfandre et al., 2017; Hasan et al., 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEstimates indicate DAMA occurs for around 2% of all hospitalizations, however, rates as high as 20% have been reported from specific institutions (Alfandre, 2009; Southern et al., 2007). Patients discharged against medical advice are at substantially increased risks of re-admission and mortality compared to those discharged regularly (Aliyu, 2002; Jerrard, 2016).\u003c/p\u003e\n\u003cp\u003eDAMA is an important, yet understudied aspect of the healthcare system, particularly in African populations\u0026nbsp;(Abuzeyad et al., 2021; Ekwedigwe et al., 2020). DAMA results in increased mortality, increased readmission rates, and higher healthcare costs all over the world (Abuzeyad et al., 2021; Ekwedigwe et al., 2020). According to available studies, DAMA has varying rates and causes based on the illness or condition, geographical area, and kind of treatment the health system provides (Albayati et al., 2021; GELPERIN, 1959; Hasan et al., 2019; Kraut et al., 2013; Noohi et al., 2013; Pasay-An et al., 2022; WILMER, 1955). It is a phenomenon that is not uncommon with an incidence rate that ranges between 0.8% and 2.2% of discharges from different teaching and tertiary care hospitals worldwide (Alfandre et al., 2017; Bartley, 2014; Fiscella et al., 2007; Kraut et al., 2013; Pasay-An et al., 2022). The phenomenon is even more a\u0026nbsp;significant problem in emergency departments (EDs) across various health facilities (Abuzeyad et al., 2021; Alkahtani \u0026amp; Shujaa, 2021; Brenner et al., 2016; Ekwedigwe et al., 2020; Jerrard \u0026amp; Chasm, 2011; Lee et al., 2016; Noohi et al., 2013; Puri Singh et al., 2016; Sayed et al., 2016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the United States each year, roughly 500,000 people, or 1-2 per cent of all hospital discharges, are classified as DAMA. (Abuzeyad et al., 2021; Lee et al., 2016; Sayed et al., 2016).\u0026nbsp;This problem is not limited to the United States, a prior UK study discovered that 0.73 per cent of ED patients took DAMA and that 3% did not wait to be seen at all.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;DAMA has been linked to negative health outcomes and poor health service usage results when compared to those with scheduled discharges. These consequences include lower follow-up appointment attendance rates and greater rates of readmission, mortality, and recurrent DAMA episodes (Albayati et al., 2021; Ekwedigwe et al., 2020; Paul et al., 2019; Southern et al., 2012). In retrospective matched cohort research in 2011 with 656 patients, Choi et al. discovered that patients who left with DAMA had a 12-fold increased risk of readmission relative to the non-DAMA group. Additionally, they discovered that the 12-month all-cause mortality was higher in the DAMA group (6.7 per cent vs. 2.4 per cent, p = 0.01)\u0026nbsp;(Choi et al., 2011; Lee et al., 2016). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese higher death rates, readmission rates to hospitals and the anticipated total costs of DAMA on the healthcare system, undoubtedly impose a huge economic burden on the patient and government (Albayati et al., 2021; Alfandre, 2013; Edmunds et al., 2012). Meanwhile, the treating physicians may find it difficult to keep their oath to act in the patient\u0026apos;s best interest and honour their preferences. This issue has a significant impact on both patients and physicians alike (Alfandre, 2013; Harel et al., 2016; Jeremiah et al., 1995; Levy et al., 2012; Pytell \u0026amp; Rastegar, 2018).\u003c/p\u003e\n\u003cp\u003eA study conducted in 2012 by the Healthcare Cost and Utilization Project found that DAMA increased by 41% between 1997 and 2011 (Pfuntner et al., 2011). Studies conducted at numerous tertiary care facilities in low- and middle-income nations indicate that DAMA rates were far higher than those stated in high-income countries (Albayati et al., 2021; Alfandre, 2013). Many such studies from lower and middle-income countries report a prevalence rate of about 2.4% to as high as 25.8% (Alfandre, 2013; Alkahtani \u0026amp; Shujaa, 2021; Mensah, 2020). Due to the disease process and insufficient treatment, these patients frequently have severe illness at the time of self-discharge, which raises the possibility of death or the need for readmission (Baptist et al., 2007; Choi et al., 2011; Hwang et al., 2003; Lee et al., 2016; Levy et al., 2012).\u003c/p\u003e\n\u003cp\u003eIn Western countries, individuals admitted for mental health illnesses, substance misuse, as well as Human Immunodeficiency Virus positive (HIV) cases are most prone to encounter a DAMA incident (Baptist et al., 2007; Gerace et al., 1995; J. et al., 2012; Palepu et al., n.d.; Porter et al., 2012; Senior \u0026amp; Kibbee, 1986; Simon et al., 2020). Among HIV-infected patients, the rates of DAMA discharge range from 10% to 30% (Giordano et al., 2009; Southern et al., 2012; Torian \u0026amp; Wiewel, 2011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDAMA is predicted by patient-related factors such as younger age, male sex, low socioeconomic level, lack of insurance, and history of substance misuse in low-middle-income countries (Alfandre, 2013; Howard \u0026amp; Holmshaw, 2010; Lekas et al., 2016). Some studies also suggest that poor socioeconomic standing (low income and poor insurance status) principally explains DAMA (Abbani et al., 2023; Alkahtani \u0026amp; Shujaa, 2021; Puri Singh et al., 2016; Spooner et al., 2017; Yusuf et al., 2017). In recent times, particularly in Ghana and the entire African Sub-region, faith-based healing is well-advertised and is likely accounting for more numbers of patients seeking DAMA although no current objective research has been done on this subject matter (Bayor \u0026amp; Kojo Korsah, 2023; Gk \u0026amp; Pi, 2013; Mensah, 2020).\u003c/p\u003e\n\u003ch3 id=\"_Toc165382740\"\u003eStatement of the Problem\u003c/h3\u003e\n\u003cp\u003eAccording to the data available on the DAMA phenomenon, the proportion of DAMA patients makes up a very minor portion of all hospital discharges (Alfandre, 2018; Spooner et al., 2017). These are however significant since DAMA patients typically experience worse medical and surgical outcomes (Alfandre et al., 2017; Southern et al., 2012). The poor potential outcomes include but are not amputations, disfiguring scars, high readmission and death rates (Albayati et al., 2021; Ekwedigwe et al., 2020; Kavanagh et al., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDAMA cases are also a high potential source of disease spread in the community. They are a potential source of both disease and treatment resistance and as such of a public health concern worldwide (Alfandre, 2018; Brenner et al., 2016; Holmes et al., 2021; Kavanagh et al., 2020; Pasay-An et al., 2022; Tr\u0026eacute;panier et al., 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTheir long-term ill state tends to add to the patient burden and load for health workers and healthcare facilities (Albayati et al., 2021; Noohi et al., 2013). Most DAMA cases are a drain on the national economy since their ill state does not permit them to contribute meaningfully to the economy and long treatments increase direct healthcare costs in the country (Alagappan et al., 2023; Pasay-An et al., 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGlobal and sub-regional trends over the past years are readily not available but estimates put DAMA rates between 1% to 2% and it is steadily growing fast, especially in sub-Sahara Africa and the Middle East (Akinbodewa et al., 2016; Alidoust \u0026amp; Yahyavi, 2022; Mensah, 2020; Mohseni et al., 2015). Many facilities and departments such as the Orthopedics and Trauma department and Emergency department report higher rates (25.9%) (B.M. et al., 2015; M.E. et al., 2014; Menendez et al., 2015). DAMA rates are also significantly higher in patients with chronic conditions such as hypertension, diabetes mellitus, sexual weakness, psychiatric patients, substance abuse patients, and HIV-positive patients. These patients are usually managed over long periods and rarely get cured medically (Aljuhani, 2022; Howard \u0026amp; Holmshaw, 2010; Molina-Mula et al., 2018; Muzyk et al., 2019; Spooner et al., 2017; Torian \u0026amp; Wiewel, 2011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe researcher\u0026rsquo;s observations and accounts from health staff at the A\u0026amp;E, orthopaedic, neurosurgical, and medical departments especially show that many DAMA patients come back to the hospital in a worse state and are saved through more radical procedures and expensive medications that scar and further improvise these patients for life.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDAMA also continues to wane down the morale and motivation of health personnel at the various departments. They see daily their best efforts go down the drain when patients request DAMA and derail their treatment plans (Jimoh et al., 2015; Molina-Mula et al., 2018; Muzyk et al., 2019).\u003c/p\u003e\n\u003cp\u003eThere has been little research done on the DAMA phenomenon in Ghana and where done, it is usually case or department-based.\u003c/p\u003e\n\u003cp\u003eThe Tamale Teaching Hospital is currently the main and biggest health facility in the Northern part of Ghana which serves a little over 5.8 million people\u0026nbsp;(Ghana Statistical Service, 2021). This study will yield further insight into the DAMA phenomena for a wide area and varied groups of people. The proposed recommendations when implemented will have far-reaching impacts on many lives across a wide geographical area.\u003c/p\u003e\n\u003cp\u003eAlso, the study findings will contribute to the body of knowledge already available on the prevalence of DAMA in Ghana and help give evidence for the development of interventions aimed at lowering the level of DAMA in Ghana, Africa, and the world at large.\u0026nbsp;\u003c/p\u003e"},{"header":"METHODOLOGY","content":"\u003ch3\u003eStudy Area: Tamale Teaching Hospital \u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eTamale Teaching Hospital is within Ghana\u0026apos;s Northern Region\u0026apos;s Tamale Metropolis. Tamale is the sole metropolis in the north and one of the six (6) Metropolitan Assemblies in the nation. Tamale also doubles as both the Metropolitan and Northern Regional capitals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Republic of Ghana\u0026apos;s Constitution\u0026apos;s legislative instrument, L.I. 2068, established the Tamale Metropolitan Area. Part of the 16 Metropolitan, Municipal, and District Assemblies (MMDAs) in the Northern Region, Ghana. Tamale\u0026nbsp;is the capital of the Metropolis and it lies between latitudes 9.16\u0026deg; and 9.34\u0026deg; North and longitudes 00.36\u0026deg;and 00.57 west, with an estimated land size of 731 square kilometres according to the 2021 Population and Housing Census (PHC) (2021 PHC Report). Located in the nation\u0026apos;s Savannah Woodland Region, the Metropolis borders the to the northwest, the Mion District to the east, the South Gonja, the South West, and the East Gonja.\u003c/p\u003e\n\u003cp\u003eThe Tamale Metropolis\u0026apos; population was estimated by the Population and Housing Census (PHC) of 2021 to be 374,744 which is urban. It had 189,693 (50.6 per cent) females and 185,051 (49.4%) males. (Ghana Statistical Service, 2022; Ghana Statistical Services., 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAccording to the 2021 Population and Housing Census, the population of the Metropolis is 223,252 representing 9.4 percent of the region\u0026rsquo;s population. Eighty-eight per cent of the population lives in urban regions, while the remaining percentage is in rural areas (19.1 per cent).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn terms of ethnicity, The Dagomba people are the original inhabitants of the Metropolis, however, it is now home to a variety of ethnic and tribal groups. Dagombas make up more than 80% of the population of the Metropolis. The Gonja, Mamprusi, Nanumba, Konkomba, Asantes, Ewes, Hausa, and a few other minorities are some more tribal groupings. The Metropolis needs intertribal collaboration for peace and development, which makes this composition crucial.\u003c/p\u003e\n\u003cp\u003eThe major healthcare provider within the Metropolis is the public sector, whose services are augmented by several private clinics, pharmacies, and over-the-counter chemical sellers. The Tamale Teaching Hospital (TTH), Tamale Central/Regional Hospital (TCH), and Tamale West Hospital (TWH) are the main public health hospitals in the Metropolis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHowever, the indigenes\u0026apos; proximity to TTH has caused a further impact on health-seeking behaviour in that, there is an easy spread of disinformation and misinformation about the hospital. this spread of news rightly or wrongly is usually not done with malice intended but is mostly exaggerated with half-truths and untruths (Kanton et al., 2023; Lekuu \u0026amp; Yidana, 2023). Many people within the metropolis have the perception of dying when asked to seek healthcare at TTH and will generally come to TTH as the least lender of the resort. This behaviour leads many to come to TTH in a very bad state and when they die from the complications resulting from the delay, it further feeds the narrative of people dying at the hospital (Bayor \u0026amp; Kojo Korsah, 2023; Kanton et al., 2023; Lekuu \u0026amp; Yidana, 2023; Mensah, 2020).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe northern part of the Ghana in particular has a very poor road and transportation networks. Its population is the poorest in the country, so many delays in seeking healthcare due to financial constraints and difficulty getting to the facility. The above reasons make the hospital to usually receive cases already with complications and very bad state. These cases with poor prognosis at arrival after dying leave very emotional relatives who used their \u0026lsquo;last penny\u0026rsquo; to get to TTH with the hope of a cure. These relatives in telling their stories are mostly anything but objective. These stories go a long way to lead more patients with avoidable death conditions to report late after wasting most of their time visiting other sources of healing before they are brought to TTH in a state where little to nothing can be done to serve their lives. (Ghana Statistical Service, 2014; Kanton et al., 2023; Lekuu \u0026amp; Yidana, 2023; Lioce et al., 2020; Mensah, 2020; Mohammed et al., 2022; Nuhu, 2016). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current population of the five (5) regions is approximated at 5.8 million (Ghana Statistical Service, 2021). The hospital also serves most parts of, the northern parts of Oti, Volta, and Bone East Regions with an approximate population of about 3.6 million (Ghana Statistical Service, 2022; Lekuu \u0026amp; Yidana, 2023). There is evidence that people from the Southern Regions, mainly Greater Accra and Greater Kumasi areas also visit TTH for healthcare services due to the low cost of services compared to the other tertiary facilities in the country (DOSOO et al., 2020; GHS, 2017). In light of its medical tourism potential, it also manages cases from some West African neighbours, mainly Burkina Faso, Togo, Benin, and Sierra Leone (DOSOO et al., 2020).\u003c/p\u003e\n\u003cp\u003eThe hospital is located about two (2) kilometres southeast of Tamale, the capital of the Northern Region, and collaborates with the University for Development Studies (UDS), Tamale campus to offer undergraduate and graduate programs in Medicine, Nursing, and Nutrition amongst others. It was the third teaching hospital opened in Ghana after the Korle Bu Teaching Hospital and the Komfo Anokye Teaching Hospital \u003c!--[if supportFields]\u003e\u003cspan style='mso-element:field-begin'\u003e\u003c/span\u003e\u0026nbsp;CITATION Min06 \\l 1033 \u003cspan style='mso-element:field-separator'\u003e\u003c/span\u003e\u003c![endif]--\u003e(Ministry of Health, 2006)\u003c!--[if supportFields]\u003e\u003cspan style='mso-element:field-end'\u003e\u003c/span\u003e\u003c![endif]--\u003e. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eJustification for Choice of Study Area\u003c/h3\u003e\n\u003cp\u003eTamale Teaching Hospital is currently the main and biggest referral centre in the northern part of Ghana. The hospital receives referrals from all the regional hospitals and other health facilities in the Northern, Savannah, North East, Upper East and Upper West, Oti, Volta, and Bono East Regions with a current population of over 5.8 million according to Ghana 2021 population and housing census (Ghana Statistical Service, 2021, 2022).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFrom the research\u0026apos;s observations, TTH is a complex mix of various medical and surgery specialties which most patients find cumbersome to navigate around to attain health care and this easily gets patients and relatives frustrated with the system. TTH has also gained a bad reportage and reputation, especially among the locals of the Tamale Metropolis due to the many systemic and operational difficulties within the facility leading to many patients quickly and eagerly seeking DAMA.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study in this facility will give an insight into the DAMA phenomena for a wide group of the population over a large geographical area and the solutions proposed when implemented will have far-reaching impacts on many lives.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eStudy Design\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eA retrospective descriptive cross-sectional design was employed in this study. The research used quantitative method (Rezigalla, 2020; Somasundaran, 2022; Spector, 2019; Srikanth \u0026amp; Doddamani, 2013; Thiese, 2014; Tranfield et al., 2003).\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eThe study population involved all patients who were admitted to the Tamale Teaching Hospital when the electronic folder (efolder) system known as the (Light-wave Hospital Information Management System (LHIMS) was introduced. Who requested and were granted DAMA from 1\u003csup\u003est\u003c/sup\u003e December 2020 to 30\u003csup\u003eth\u003c/sup\u003e June 2023. This is irrespective of any particular parameter. They just needed to be patients who requested and were granted DAMA during the period of study.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eInclusion criteria\u0026nbsp;\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAll entries included in the study were patients managed at TTH between\u0026nbsp;1\u003csup\u003est\u003c/sup\u003e December 2020 to 30th June 2023 and the entry should also be correctly filled on the LHIMS to have requested and granted DAMA.\u003c/p\u003e\n\u003cp\u003eDAMA is a distinct category that patients are electronically placed in before they leave the hospital by the discharging physician. \u0026nbsp;A list of all patients who took DAMA during the study period was generated and their records were extracted. All patients who left TTH based on DAMA have a signed DAMA letter that is vetted and approved by the discharging doctor.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eExclusion criteria\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAn entry was excluded from the study if patient documentation was not correctly filled or there was no proper proof by documentation of DAMA.\u003c/p\u003e\n\u003ch3\u003eSampling Technique and Sample Size Determination\u003c/h3\u003e\n\u003cp\u003eAll available records on patients who took DAMA during their management at TTH for the study period were used. Thus, a census was conducted for all individuals who sought DAMA during the research period.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study period saw about 53,342 people admitted to the Tamale Teaching Hospital through the various departments. \u0026nbsp;Of the 53, 342 patients, 941 of them sought and were granted DAMA. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll patients who took DAMA were included.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eData source\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eSecondary data from patients\u0026apos; records on the Light-wave Hospital Information Management System (LHIMS) of all those who took DAMA were extracted for the research.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eIndicators Assessed in the Study\u003c/h3\u003e\n\u003cp\u003eThe main indicators in this study were the sociodemographic data, the prevalence and the different prevalence among the various d\u0026eacute;partements. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003e\u0026nbsp;Data Collection Instruments\u003c/h3\u003e\n\u003cp\u003eA structured guide using Microsoft Excel was used for the extraction of data of DAMA patients information from their efolders.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\n\u003cp\u003eThe secondary data had components; sociodemographic characteristics (age, sex, marital status, religion, occupation,\u0026nbsp;and insurance status) and the hospital admission record of the department were extracted into the already prepared structured guide on Microsoft Excel which was then cleaned after the extraction for further analyses in SPSS version 26.\u003c/p\u003e\n\u003ch3\u003eData Quality Control\u003c/h3\u003e\n\u003cp\u003eTo ensure the accuracy and validity of data collected in this study, the following measures were put in place:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe structured guides that were used for data extraction and collection of the secondary data was designed in close reference with already published works. The research objectives set to answer the identified research questions also guided the design. Pretesting of all structured guides used in this study was done at the Accident and Emergency Department of TTH.\u003c/p\u003e\n\u003cp\u003eData was safely and securely stored on the researchers\u0026rsquo; personal computers. No other persons had access to the data for possible distortion and manipulation.\u003c/p\u003e\n\u003cp\u003eBefore data analysis, data cleaning was undertaken to get a data set that was sufficiently consistent to permit precise analysis.\u003c/p\u003e\n\u003ch3\u003eStrengths of the Study\u003c/h3\u003e\n\u003cp\u003eThe study was more precise since no sampling was done. The study was generally affordable and had limited information and recall bias.\u003c/p\u003e\n\u003cp\u003eThe study also covered a wide scope since the hospital receives patients from five (5) Regions.\u003c/p\u003e\n\u003ch3\u003eInformed consent\u003c/h3\u003e\n\u003cp\u003eThere were no individual consent forms signed by DAMA patients since it was a retrospective study. Nonetheless, ethical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST). The ethical approval number CHRPE/AP/1021/23, dated 16\u003csup\u003eth\u003c/sup\u003e November, 2023, enabled data extraction without individual consent from the already discharged patients. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData Analysis Plan\u003c/h3\u003e\n\u003cp\u003eData was retrieved from LHIMS and collected into a Microsoft Excel application. It was then cleaned, coded, and imported into SPSS version 26. The SPSS software was further used to refine the data and to categorize it into continuous variables and discrete variables for easy analysis.\u003c/p\u003e\n\u003cp\u003eIn the univariate analysis that was done, descriptive statistics was calculated for the total study sample, and variables were summarized by their frequency distributions whereas numeric variables; continuous and discrete variables will be presented as percentiles.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eSocio-demographic Characteristics of the Study Population\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe total number of patients admitted to the Tamale Teaching Hospital during the study period (1\u003csup\u003est\u003c/sup\u003e December 2020 to 30 June 2023) was 53,342 for all the departments. 941 of these patients requested and were granted DAMA resulting in a prevalence rate of 1.76%. The Socio-demographic Characteristics of these patients are presented in Table 1. The majority of DAMA patients were male 667 (70.88%) and 274 (29.11%) were female.\u003c/p\u003e\n\u003cp\u003eRegarding the age, majority, 650 (69.08%) were in the economically productive age group (between the ages of 20 to 61 years) while 291 (30.92%) were in the dependent age group (patients between the ages of 0 to 20 and those above 60 years).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDuring the extraction process, some 264 (28.06%) of the DAMA patients had missing records of educational status. However, those with no form of education were greater; 280 (29.54%). Patients with basic education were 181 (19.23%) while those with secondary education were 119 (12.65%). Patients with tertiary education 97 (10.31%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe majority of patients who took DAMA 573 (60.89%), had no form of health insurance to pay for their medical bills and thus had to pay out of pocket for all the services they received at the hospital. Quite a significant number, 368 (39.11%) were on the National Health Insurance Scheme (NHIS). No DAMA patient had any other form of Insurance.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, 144 (15.30%) patients who took DAMA documented that they were single while 241 (25.61%) were identified as married. However, 45 (4.78%) patients were widowed and 89 (9.46%) were divorced. Patients below the legal age of marriage in Ghana were captured as not applicable; less than 18 years; 237 (25.19%). On the other hand, 185 (19.66%) patients had missing records for marital status.\u003c/p\u003e\n\u003cp\u003eA total of 216 DAMA patients\u0026rsquo; records did not include their religious affiliation however, 203 (21.57%) were identified as Christians, 506 (53.77%) belonged to Islam and 16 (1.70%) practised African traditional region.\u003c/p\u003e\n\u003cp\u003eEmployment status was not applicable for patients below the legal age of 18 years in Ghana. However, it was noticed that some 16 and 17-year-olds were gainfully employed. A total of 205 (21.79%) were categorized as not applicable. The majority 289 (30.71%) had no records for employment so they were classified as missing. Employed and unemployed had a total of 232 (24.65%) and 215 (22.84%) respectively.\u003c/p\u003e\n\u003cp\u003eThe majority 642 (68.23%) of patients had no records for their Region of residence, however, the Northern Region recorded 151 (16.05%) patients, 75 (7.97%) patients were from the Upper East Region, 38 (4.04%) patients were from the Upper West Region, 19 (2.02%) patients were from the Savanna Region and 16 (1.70%) patients were from the North East Region.\u003c/p\u003e\n\u003cp\u003eFinally, the occupation variable had farming as the single leading job with a total patient number of 97 (10.30%), closely followed by private artisanship workers with 93 (9.88%), then traders and drivers closely followed with 62 (6.59%) and 53 (5.63%) respectively. Civil servants were 36 (3.83%) and other occupations were 106 (11.26%). Table 1 below depicts the summary of the socio-demographic discussed above\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Socio-demographic Characteristics of the Study Population (N=941)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e667\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e70.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e274\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e29.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0-10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e108\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11.48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11-20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e148\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e15.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e21-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e263\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e27.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e31-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e182\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e41-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e162\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e17.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e51-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e4.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e61-70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e71+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNo Education\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e29.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eBasic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e181\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSecondary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e12.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eTertiary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e10.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e264\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e28.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNHIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e368\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e39.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003ePrivate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNo Insurance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e60.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarital Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e144\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e15.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e241\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e25.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e4.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eDivorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e89\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e237\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e25.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e185\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eReligion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eChristianity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e21.57\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eIslam\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e506\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e53.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eAfrican Traditional Religion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e22.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eEmployment Status\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eUnemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e215\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e22.84\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e232\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e24.65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e21.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e30.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eRegion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNorthern\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e16.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eSavannah\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e2.02\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNorth East\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e1.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eUpper East\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e7.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eUpper West\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e4.04\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e642\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e68.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eOccupation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eFarming\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e10.30\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eArtisanship/Business/Private work\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e93\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e9.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eTrading\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e6.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eDriver\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e5.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eCivil Servant\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e3.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e106\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e11.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eNot applicable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e21.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003eMissing record\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e289\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 125px;\"\u003e\n \u003cp\u003e30.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSource: Field Survey 2023\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc165382797\"\u003e\u003cstrong\u003ePrevalence Rate of DAMA in various Departments at the Tamale Teaching Hospital\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were varying prevalence rates within the seven (7) main departments at the Tamale Teaching Hospital. The overall prevalence rate of DAMA at TTH was 1.76%. The Accident and Emergency Department recorded the highest rate of 3.26% to 1.76% in the whole hospital followed by a 2.25% prevalence rate in the Medicine and Therapeutics department. The polyclinic department recorded prevalence a rate of 1.72%. The Department of Surgery recorded a prevalence rate of 1.54%. A prevalence rate of 0.86 was obtained at the Department of Obstetrics and Gynecology. The pediatric department closely followed with a rate of 0.80 while the dental department recorded no DAMA cases so a prevalence rate of 0. These prevalence rates are shown in Figure 1 below.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Accident and Emergency Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Accident and Emergency department had a total of 11,727 admissions for the study period which made up 21.98% of the total admissions to the hospital. This department contributed 382 (40.59%) of the total number of participants in the research who took DAMA, shown in Figure 2 and Table 2. The department had a DAMA prevalence rate of 3.26%. Within the three (3) zones that make up the A\u0026amp;E department, the majority 234 (61.25%) of the patients who took DAMA were from the orange zone, followed by the yellow zone with 87 (22.77%) and was red zone with a total of 61 (15.97%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Surgery Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdmissions of 10,851 were recorded in this department, making up 20.34% of the total admissions at TTH. The surgery department had a total of 167 DAMA patients shown in Figure 2 and Table 2. This represented 17.74% of all DAMA at TTH and a departmental prevalence rate of 1.54%. The sub-specialities within the department made different levels of contributions to the total number of DAMA cases.\u003c/p\u003e\n\u003cp\u003eTwo (2) sub-specialties made up more than 70% of the total DAMA cases in the department. Neurosurgical contributed 74 (44.31%) while Trauma and Orthopaedics with 43 (25.74%). The other seven (7) sub-specialities make up the rest of the less than 30%. General surgery recorded 17 (10.18%), pediatric surgery 9 (5.39%), ophthalmology 8 (4.79%), urology 6 (3.59%), Thoracic surgery 5(2.99%), plastic surgery 3 (1.80%) and that of Ear, Nose and Throat 2 (1.20%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Paediatrics Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis department had a total of 10,205 making up 19.13% of total admissions to TTH. The total number of patients who were granted DAMA was 82 which made up 8.71% of the total DAMA cases from TTH. The total number of DAMA cases for the department is shown in Figure 2 above and Table 2. The department had a prevalence rate of 0.80%. this department has the Emergency sub-unit, which had a total of 17 (20.73%) DAMA patients, the children\u0026rsquo;s ward which had 65 (79.23%), and the Neonatal Intensive Care Unit (NICU) which had no DAMA granted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMedicine and Therapeutics Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe medical department had a total of 7,513 admissions over the study period which represented a total of 14.08% of the total admissions to TTH. The department had 169 cases take DAMA over the study period, as shown in Figure 2 and Table 2 below. This number accounted for 17.96% of all DAMA cases in the hospital. A prevalence rate of 2.25%. the department\u0026rsquo;s three (3) floors; M1 had a total of 41(24.26%) patients taking DAMA, M2 had 49 (28.99) DAMA and M3 made up the majority of 79 (46.75%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObstetrics and Gynaecology Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAdmissions were 9,122 over the two-and-a-half (2 \u0026frac12;) year period, which made up 17.10% of the total admissions at TTH. The O\u0026amp;G department saw a 78-patient discharged using DAMA, which contributed 8.29% to the total number of DAMA cases at TTH. The total number of DAMA cases for the department is shown in Figure 2 and Table 2. This department had a 0.86% prevalence rate, the Gynaecology wards contributed 61 (78.21%) to the total DAMA in the department while Obstetric wards made up 17 (21.79%) but the labour ward had no recorded DAMA cases\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Polyclinic Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Polyclinic Department contributed a total of 3,673 admissions to the hospital making up 6.89% of total admissions. The number of patients who were granted DAMA was 63 which made up 6.70% of the total DAMA cases recorded at TTH over the study period. The total number of DAMA cases for the department is shown in figure 2 and Table 2. A prevalence rate of 1.72% was recorded in this department. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Dentistry Department\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe dentistry department had a total of 251 admissions over the study period which represented 0.47% of total admissions to TTH. There was no DAMA case seen from this department as shown in Table 2.\u003c/p\u003e\n\u003cp id=\"_Toc157736364\"\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e: Summary of Departmental Information on DAMA at the TTH\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"514\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepartment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccident and Emergency\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e11,727\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e21.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e382\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e40.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eZones in the Department\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eYellow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e87\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e22.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eOrange\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e61.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eRed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e15.97\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgery\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eAdmissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e10,851\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e20.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eDama\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e167\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSub-Specialty\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNeurosurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e44.31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTrauma And Orthopaedics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e25.74\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eGeneral Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e10.18\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePediatric Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e5.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eOphthalmology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e4.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eUrology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eThoracic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePlastic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eEar, Nose, and Throat\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaediatrics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e10,205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e19.13\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e8.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0.80\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSub-units\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eEmergency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e20.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eWard\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e79.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eNICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedicine and therapeutics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e7,513\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e14.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e169\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17.96\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e2.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eFloors\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedial 1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e24.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedical 2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e28.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eMedical 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e46.75\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eObstetrics and Gynaecology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e9,122\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17.10\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e8.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eSub-unit\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eGynaecological ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e78.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eObstetric ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e21.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eLabour ward\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePolyclinic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e3,673\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e6.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e1.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDentistry\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003eTotal Admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePatients who took DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003ePrevalence of DAMA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 129px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eSource: Field Survey, 2023\u003c/strong\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003ch3\u003eSocio-demographic Characteristics of Study Population.\u003c/h3\u003e\n\u003cp\u003eThe total number of patients admitted to TTH during the study period was 53,342 while 941 of these patients requested and were granted DAMA. This resulted in a DAMA prevalence rate of 1.76% for the study period. The prevalence is consistent with the global rate of between 0.07- 20% (Alfandre et al., 2017; Gk \u0026amp; Pi, 2013; Spooner et al., 2017). In a study conducted at the same hospital, TTH although just from one (1) department, the prevalence rate was 2.5% not far off what this study unearthed (Bayor \u0026amp; Kojo Korsah, 2023). These findings are also similar to other regional rates. In Nigeria, rates of 3.8% and 4.5% were obtained in two (2) studies conducted in Abuja, Nigeria (Gk \u0026amp; Pi, 2013; Yusuf et al., 2017). A study in the UK also unearthed a rate of 3% while one in the U.S.A. was 0.9% (Alagappan et al., 2023; Sayed et al., 2016; Spooner et al., 2017). These varying prevalence rates were generally impacted by the geographical and type of hospital at which the study was conducted (Alkahtani \u0026amp; Shujaa, 2021; Spooner et al., 2017). This prevalence rate of DAMA at TTH has very significant and grave consequences for patients especially but also for the hospital, the general health system, and the country as a whole. These number of patients are generally improvised since they are economically inactive during, the long duration of illness which directly affects their dependents if any, or burdens for their caregivers and relatives. The hospital generally loses money from the termination of their admissions, the hospital infrastructure and staff are also stressed since the majority of these DAMA cases will come back on admission usually in a worse state for management. Health services delivered to patients are generally subsidized by the government of Ghana. In the long term, the government spends more money to subsidize services for these patients. The majority of these patients seek multiple care from the same hospital or other health facilities after seeking further putting stress on the government and its other agencies such as the NHIS and the welfare service (Fenny et al., 2015; Mensah, 2020; Pasay-An et al., 2022). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe analysis of the characteristics of the study group showed that the majority were male repenting a total of 667 (70.88%) and the other 274 (29.11%) were female. TTH serves an area where motorbikes and tricycles are the common means of transportation and are usually ridden by males with no helmets on. Accidents often occur leaving many injured. In many cases, which involve men, seek DAMA after initial assessment quickly (Abuzeyad et al., 2021; Sayed et al., 2016; Tr\u0026eacute;panier et al., 2023).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA study at the TTH emergency department found that men usually have socioeconomic responsibilities of family upkeep and are more likely to avoid hospitalization to reduce the cost of health care (Bayor \u0026amp; Kojo Korsah, 2023). Females are also generally known to be more compliant with medical care and more concerned about their health. They will often need to be fully fit before discharge (Alkahtani \u0026amp; Shujaa, 2021; Bayor \u0026amp; Kojo Korsah, 2023; Jimoh et al., 2015; Mohseni et al., 2015; Noohi et al., 2013). These rates are also consistent with other studies done in Nigeria where males were 57.3% to 42.7% of females (Gk \u0026amp; Pi, 2013)and similar rates were also observed in other studies around the globe (Alfandre, 2018; Hasan et al., 2019; Pasay-An et al., 2022; Spooner et al., 2017; Yusuf et al., 2017). Similar results were also obtained from studies conducted at single departments and whole hospitals in Lebanon, Saudi, Nigeria, and the UK (Akinbodewa et al., 2016; Alagappan et al., 2023; Alkahtani \u0026amp; Shujaa, 2021; Tr\u0026eacute;panier et al., 2023; Yusuf et al., 2017). The northern sector of Ghana has many men as the solo breadwinners of their nuclei and extended families. Many men usually taking DAMA with its attended complications leave many of their families improvised and burdened. \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding the age, majority, 650 (69.08%) were in the economically productive age group (between the ages of 21 to 60 years) while 291 (30.92%) were in the dependent age group (patients between the ages of 0 to 20 and those above 61 years). \u0026nbsp;DAMA complications cause the majority of these economically active people to stay inactive over long periods which impacts their finances directly and broader impacts the gross domestic product of the country.\u003c/p\u003e\n\u003cp\u003eMany of the DAMA patients 573 (60.89%) had no form of insurance and had to pay out of pocket. The group enrolled on the NHIS had to pay top-ups for most services rendered to them. However, NHIS makes a big difference in total health costs and many people appreciate this fact when they seek health without any form of insurance. Not surprisingly, private health insurance has full coverage for all services received and as such no patient with this kind of insurance took DAMA. \u0026nbsp;Although many other factors lead to patients seeking DAMA, many are willing to forego any other reason and stay on admission till medically advised discharge so long as they are paying nothing out of pocket (Hwang et al., 2003; Sayah et al., 2014; Tr\u0026eacute;panier et al., 2023). Other studies done in the US also showed that patients with private insurance were less likely to seek DAMA compared to patients on MEDICARE or paying out of pocket (Albayati et al., 2021). These findings are consistent with other studies that cover the topic of insurance in DAMA patients as well (Hasan et al., 2019; Noohi et al., 2013). Many of these patients were already burdened with responsibilities as breadwinners of families and usually wanted to spend as little time and money at the hospital. \u0026nbsp;Many families found in these poorest regions of the country are barely surviving and do not earn enough to afford a form of proper health insurance which many see as expansive and out of their reach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEducation as a variable also saw 264 (28.06%) of the DAMA patients having missing records for educational status. \u0026nbsp;Aside from those with missing records, those with no form of education were 280 (29.54%), followed by those with basic education 181 (19.23%) secondary education with 119 (12.65%) and tertiary education 97 (10.31%). Compared to another study done at the TTH A\u0026amp;E department, 85 (40.5%) had missing records and had fewer patients 55 (26.2%) being uneducated compared to educated patients of 70 (33.3%) (Bayor \u0026amp; Kojo Korsah, 2023). One can make an inference from observations that most patients with missing records on education most likely had no form of education. The records staff would usually skip this part during the registration process when responses are not forthcoming (Abbani et al., 2023; Maier et al., 2023; Mohammed et al., 2022). With this inference in mind, one can state that the majority of patients 544 (57.81%) who sought DAMA had no form of education. \u0026nbsp;Moreso, in this part of the world where education is usually directly linked with good opportunities for jobs and a relatively good amount of wealth which enables them to afford health care compared to the rest of the general population (Abuzeyad et al., 2021; Alfandre, 2018; Alfandre et al., 2017; Alkahtani \u0026amp; Shujaa, 2021; Bayor \u0026amp; Kojo Korsah, 2023; Choi et al., 2011; Mohseni et al., 2015; Pytell \u0026amp; Rastegar, 2018; Sayed et al., 2016; Yong et al., 2013).\u003c/p\u003e\n\u003cp\u003eOf the patients missing records for marital status 185 (19.66%), 241 (25.61%) were married, 89 (9.46%) were divorced while 237 (25.19%) of the patients below 18 years, the legal age for marriage in Ghana so were categorized as not applicable. Other research papers done in the subregion and globally varied greatly. This variable through lecture had less impact on a person\u0026rsquo;s decision to take DAMA or not (Abbani et al., 2023; Alfandre, 2018; Sayed et al., 2016).\u003c/p\u003e\n\u003cp\u003eThe majority 505 (53.77%) of DAMA patients identified as belonging to Islam while 203 (21.57%) identified as Christians. A few 16 (1.70%) of them identified as Traditionalist and as many as 216 (22.95%) patients had missing records for this variable. Findings were for the most part consistent with findings in a prior study done at TTH (Bayor \u0026amp; Kojo Korsah, 2023), however, findings variable in other studies that were done in other geographical locations across the globe (Sayed et al., 2016; Spooner et al., 2017; Tr\u0026eacute;panier et al., 2023). The local population living closer to the health facility are predominantly Muslim and as such the Islamic religious grouping contributes more to the statistics.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe employment status unearthed 289 (30.71%) without records while 205 (21.79%) patients were below the age of 16 and were legally not allowed to be employed in Ghana so were categorized as not applicable. 232 (24.65%) patients were employed in occupations such as farming 97 (10.30%), artisanship 93 (9.88), trading 62 (6.59), drivers 53 (5.63%) and 36 (3.83%) civil servants while 215 (22.84%) were documented as unemployed. However, much inference cannot be made about the employment status due to such a large number of patients with no records. Other studies done in the sub-region also showed such close divide between employed and unemployed (Abbani et al., 2023; Bayor \u0026amp; Kojo Korsah, 2023; Yusuf et al., 2017). In the developed world, the data shows otherwise, the majority of DAMA patients are documented as unemployed (Sayed et al., 2016; Spooner et al., 2017; Tr\u0026eacute;panier et al., 2023).\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc165382806\"\u003ePrevalence Rate of DAMA in various Departments at the Tamale Teaching Hospital\u003c/h3\u003e\n\u003cp\u003eThe hospital had a prevalence rate of 1.76%. Two (2) out of the seven (7) departments of the hospital recorded far higher prevalence rates. The Accident and Emergency Department and the Medicine and Therapeutics Department recorded 3.26% and 2.25% respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe A\u0026amp;E department not surprisingly, had the highest prevalence rate at the departmental level. This department is the first point of call for most cases and the data shows that most cases of DAMA do so while waiting to be moved to the wards of other departments. Most patients are most likely to seek DAMA at the point they are stable and awaiting trans out to the ward of other departments. These patients erroneously believe they are out of danger and at no risk of mortality. A similar result of 2.45% was obtained from a 2-year study done at the TTH A\u0026amp;E in 2021 (Bayor \u0026amp; Kojo Korsah, 2023). Other studies that were conducted at the A\u0026amp;E departments of other tertiary hospitals around the world also showed similar results (Bayor \u0026amp; Kojo Korsah, 2023; Ekwedigwe et al., 2020; Hasan et al., 2019).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe medicine and therapeutic department also recorded a higher rate of prevalence 2.25% compared with the general prevalence rate of 1.76%. This may likely stem from the fact that, as a tertiary facility it receives referrals from hospitals all over a wide area. Many of the population generally have poor health-seeking behaviour and many reports for care late with avoidable complications and poor prognosis. They spend many more days on admission with little to no visible improvements in their condition such as stroke, congestive cardiac failure, and chronic liver and kidney diseases. These patients are therefore for likely to seek DAMA which accounts for the relatively higher prevalence rate compared to the whole hospital. Also, these patients suffering from chronic diseases are likely to want to try faith-based healing once the doctors counsel them on the need to manage their case with no definite cure then (Alfandre et al., 2017; Asampong et al., 2015; Lekuu \u0026amp; Yidana, 2023; Mensah, 2020; Nuhu, 2016).\u003c/p\u003e\n\u003cp\u003eThe Polyclinic and Surgery departments had prevalence rates that were much closer and similar to that of the general hospital prevalence rate of 1.75%. The prevalence rates were 1.72% and 1.54% respectively. The polyclinic usually attends to stable cases who make quick recovery within short periods and are more likely to be discharged formally. The surgery department mostly gets its admissions through the A\u0026amp;E department most of the patients who are likely to seek DAMA are likely to have done so at the A\u0026amp;E department before trans-outs are done to the surgery department wards (Brenner et al., 2016; Rughani et al., 2013; Spooner et al., 2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;The Obstetrics and Gynecology department had a low prevalence rate of 0.86% compared to the whole hospital\u0026apos;s prevalence rate of 1.75%. The O\u0026amp;G department generally manages women in labour who come to delivery and will most likely not seek any DAMA. \u0026nbsp;The few DAMA cases mostly resulted from terminal gynaecological cases such as cervical and ovarian cancers. Few were also cases under post-abortion care and these with complications. These groups of patients are usually uncomfortable in an open-ended hospital and as such always have a high potential to seek DAMA. They rightly or wrongly assume and feel people will get to know them and make them victims of social mockery (Alkahtani \u0026amp; Shujaa, 2021)\u003c/p\u003e\n\u003cp\u003eThe Paediatric department recorded a prevalence rate of 0.80% which was also far below the hospital\u0026rsquo;s prevalence rate of 1.76%. The paediatric department generally by law makes seeking DAMA for minors harder for relatives compared to DAMA for adults. This system helps encourage many to rescind their decision and not go through with the DAMA. \u0026nbsp;Children\u0026rsquo;s medications, laboratory investigations and imaging are also generally cheaper and easier to get financial help from the social welfare department of the hospital. However, some few people will still tend to seek DAMA leading to such prevalence rates at the department. A study done in a paediatric ward at a university hospital in Port Harcourt Nigeria, yielded a prevalence rate of 3.8%(Alagappan et al., 2023; Gk \u0026amp; Pi, 2013) which was way higher than even the general hospital rate. Children at TTH paediatric department had NHIS which is essentially free to enrol for minors and some of the care received at the hospital.\u003c/p\u003e\n\u003cp\u003eThe dental department recorded no DAMA cases. The department mostly sees patients on an outpatient basis and even when admitted, just for a very short duration for a procedure after which patients are discharged to be followed up regularly at the outpatient clinic. The operations of this department lead to them rarely to never having patients seeking DAMA. There was no literature found on DAMA at the dental department and not surprising because is not mostly problem in this department. Their main issue is with patients self-discharging from their clinics and not showing up for regular reviews.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eAccident and Emergency Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe Accident and Emergency department had a total of 11,727 admissions for the study period which made up 21.98% of the total admissions to the hospital. \u0026nbsp;Nonetheless, this department contributed 382 (40.59%) to the total DAMA cases recorded in the hospital. The department had a DAMA prevalence rate of 3.26% compared to the general of 1.75%. Most patients are often likely to seek DAMA at the department once they are stable and believe they are out of danger and at risk of mortality. Within the three (3) zones that make up the A\u0026amp;E department admissions, the majority 234 (61.25%) of the patients who took DAMA were from the orange zone, followed by the yellow zone with 87 (22.77%), and then the red zone with a total of 61 (15.97%). The red zone cases are usually critical cases that need more medical attention so many are less likely to seek DAMA. \u0026nbsp;When compared to the other zones, the patients admitted to the yellow zone are frequently quite stable. When compared to other zones, they are typically released earlier for follow-up care in the outpatient clinic. However, patients admitted to the Orange Zone typically stay longer, which results in increased costs and additional expenses. The financial constraint is more likely to lead them to seek a DAMA since they are no longer critically ill after a few days of management. A similar result was attained in other studies across the globe done at the emergency departments of tertiary hospitals in Canada, Iran, Saudi Arabia and Nigeria (Abuzeyad et al., 2021; Alkahtani \u0026amp; Shujaa, 2021; Lee et al., 2016; Sayed et al., 2016; Tr\u0026eacute;panier et al., 2023).\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eThe Surgery Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eTotal admissions of 10,851 were recorded in this department which made up 20.34% of the total admissions at TTH. The department also contributed 167 (11.74%) to all DAMA cases in the hospital. The departmental prevalence rate of 1.54% mirrored closely to that of the hospital at 1.75%.\u003c/p\u003e\n\u003cp\u003eThe sub-specialities within the department made different levels of contributions to the total number of DAMA cases. Two (2) out of the nine (9) sub-specialities made up more than 70% of the total DAMA cases in this department, Neurosurgery sub-specialities contributed 74 (44.31%) while Trauma and Orthopaedics contributed 43 (25.74%). This is generally not surprising since the majority of DAMA causes were head injuries and fractures from road traffic accidents which are managed by these two (2) sub-specialities respectively. Road traffic accidents involving motorbike riders without crushing helmets are quite endemic in the areas served by the hospital. In other studies, done in the sub-region, the surgery department had similar results as this study unearthed. The common reason found in the literature for this DAMA prevalence rate was refusal of recommended surgery however the patients at TTH are in the habit of using financial constraints as a reason while concealing their actual reasons (B.M. et al., 2015; Jimoh et al., 2015; Tr\u0026eacute;panier et al., 2023). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe other seven (7) sub-specialities made up the rest of less than 30% of the DAMA cases recorded over the study period. These other sub-specialties may have contributed less because most of their cases are acute and life-threatening. These patients also turn to see quick improvements and are less likely to seek DAMA. A patient with a cataract can have poor vision over the years and after a cataract surgery done by the ophthalmologist which usually takes less than an hour. The next day, the patch is removed and the patient has improved vision, this is so quick a result that there enough fewer patients seeking DAMA from these sub-specialities. Throughout literature from developed and developing countries, research done in tertiary facilities, the results obtained are not so different from the surgery department (Alfandre et al., 2017; Brenner et al., 2016; Paul et al., 2019; Rughani et al., 2013; Tr\u0026eacute;panier et al., 2023).\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eThe Paediatrics Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe Paediatrics Department had a total of 10,205 making up 19.13% of total admissions to TTH. The number of patients who were granted DAMA was 82 which made up 8.71% of the total DAMA cases from TTH. The paediatric department mandated by law makes seeking DAMA for minors harder for relatives compared to DAMA for adults. This system helps encourage many to rescind their decision and not go through with the DAMA. \u0026nbsp;Children\u0026rsquo;s medications, laboratory investigations and imaging are also generally cheaper and easier to get financial help from the social welfare department of the hospital. A study conducted in a paediatric ward at a university hospital in Port Harcourt Nigeria, yielded a prevalence rate of 3.8%(Alagappan et al., 2023; Gk \u0026amp; Pi, 2013) which was way higher than even the hospital rate. \u0026nbsp;This may be because many of the children in Ghana are enrolled on the NHIS. The NHIS is essentially free to enroll for minors and many of the children\u0026rsquo;s medications and laboratory investigations needed are covered at the hospital. The department has the Emergency sub-unit, which had a total of 17 (20.73%) DAMA patients. This unit is a short transition point for patients to be stabilized before moving to the main children\u0026apos;s ward and may explain why a minority of the DAMA cases came from this unit. The children\u0026rsquo;s ward which had 65 (79.23%) DAMA cases. The unit is where patients are admitted till full recovery. The long duration of monitoring for children before discharge even after medical improvement compared to adults leads more relatives to seek DAMA. The last unit in the department is the Neonatal Intensive Care Unit (NICU). This unit had no DAMA granted and understandably so. The units take care of babies below the age of one month (from birth to 28 days old) and at this stage of life, many parents find it difficult to handle sick babies so are more likely to leave the baby at the unit when they even run out of funds than to seek DAMA. Much research done in paediatric departments in the sub-region also had similar findings. In one such study done in Abuja, Nigeria, there were no DAMA cases recorded at the NICU over the study period. A similar result was obtained in another study done in Saudi Arabia \u0026nbsp;(Alkahtani \u0026amp; Shujaa, 2021; Gk \u0026amp; Pi, 2013; Kavanagh et al., 2020).\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eThe Medicine and Therapeutics Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe medical department had a total of 7,513 admissions over the study period which represented 14.08% of the total admissions to TTH. The department had 169 cases who sought and were granted DAMA over the study period. This number accounted for 17.96% of all DAMA cases in the hospital. A prevalence rate of 2.25% was seen in the department a higher prevalence rate compared to the hospital. As the only tertiary and referral facility in the northern part of Ghana, it receives referrals from hospitals all over a wide area. The inhabitants also have poor health-seeking behaviour and many reports for care late with avoidable complications and poor prognosis. They turn to spend many more days on admission with little to no visible improvements in conditions such as stroke, congestive cardiac failure, and chronic liver and kidney diseases. These patients are therefore more likely to seek DAMA which accounts for the relatively higher prevalence rate compared to the whole hospital. Also, these patients suffering from chronic diseases are likely to want to try faith-based healing once the doctors counsel them on the need to manage their case with no definite cure then (Alfandre et al., 2017; Asampong et al., 2015; Jacobowitz, 1974; Lekuu \u0026amp; Yidana, 2023; Mensah, 2020; Nuhu, 2016).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe medical department has three (3) floors; named medical 1 (M1) which takes care of cardiovascular cases had a total of 41(24.26%) patients taking DAMA. On the second floor called medical 2 (M2) patients had 49 (28.99) DAMA cases. M2 typically cares for stroke and general neurological disease. The third and last floor, medical 3 (M3) takes care of gastroenterological cases such as chronic liver disease patients, diabetics and hypertensive. This floor contributed the majority of 79 (46.75%) of DAMA cases in the medical department. The M3 turn to manage chronically ill patients who usually do not get cured but many with the hope of getting fully cured will turn to other forms of healing. Currently, in Ghana, there are freely advertised faith-based healing and many herbal healings that rightly or wrongly \u0026lsquo;calm\u0026rsquo; to cure these chronic diseases with any regulation and checks (Bayor \u0026amp; Kojo Korsah, 2023; Kunu \u0026amp; Philip Sunday, 2021; Mensah, 2020).\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eObstetrics and Gynaecology Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eAdmissions at the department were 9,122 over the two-and-a-half (2 \u0026frac12;) year period which made up 17.10% of the total admissions at TTH. The O\u0026amp;G department saw 78 patients discharged through DAMA which contributed 8.29% to the total number of DAMA cases at TTH. This had a low prevalence rate of 0.86% compared to 1.75% of the hospital. Understandably so, the O\u0026amp;G department generally manages women in labour who come to delivery and will most likely not seek DAMA since governmental subsidies make this department one of the cheapest to seek healthcare in the hospital and even compared to other tertiary facilities in the country (DOSOO et al., 2020). The few DAMA cases resulted from terminal gynaecological cases such as cervical and ovarian cancers, some were also from post-abortion care and its complications. These groups of patients are usually uncomfortable in an open-ended hospital and as such always have a high potential to seek DAMA. They rightly or wrongly assume and feel people will get to know them and make them victims of social mockery (Alkahtani \u0026amp; Shujaa, 2021).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Gynaecology wards contributed 61 (78.21%) to the total DAMA in the department. In comparison, Obstetric wards made up 17 (21.79%). Still, the labour ward had no recorded DAMA cases since many patients who delivered were discharged from the ward after the 24 hours of monitoring without further delays leaving no room for patients to seek DAMA.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003ePolyclinic Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThis department had a total of 3,673 making up 6.89% of total admissions to TTH. The number of patients who were granted DAMA was 63 which made up 6.70% of the total DAMA cases recorded at TTH over the study period. A prevalence rate of 1.72% was recorded in this department which was much closer and similar to that of the general hospital prevalence rate of 1.72% and 1.54% respectively. The polyclinic generally attends to relatively stable cases so are more likely not to see long admissions and therefore leave little room for them to seek DAMA therefore seeing similar prevalence rates. The surgery department mostly gets its admissions through the A\u0026amp;E department most of the patients who are likely to seek DAMA are likely to have done so at the A\u0026amp;E before trans-outs are done to the surgery department wards (Brenner et al., 2016; Rughani et al., 2013; Spooner et al., 2017)\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eDentistry Department\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe dentistry department had a total of 251 admissions over the study period which represented 0.47% of total admissions to TTH. This department usually attends to most of their cases on an outpatient basis so contributed less than 1% to the total admissions in the hospital. There was no DAMA case seen from this department since this department mostly sees patients on an outpatient basis and even when admitted, just for a short duration (usually less than 2 days). Most are discharged after a few hours of monitoring on the ward after the procedure and followed up regularly at the out-patient clinic so this department rarely to never will get patients seeking DAMA. Their main issue is with patients self-discharging from their clinics and not showing up for regular reviews.\u003c/p\u003e"},{"header":"SUMMARY AND CONCLUSION","content":"\u003cp\u003e\u003cstrong\u003eSummary\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study found that the prevalence rate of DAMA at TTH was 1.76%. It also found that the majority 71% of all DAMA patients were male with 29% female. The majority (69%) were economically productive age group while 31% of all DAMA cases were not. The majority 280 (29.54%) had no form of education,216 (42.4) had some form of education and 264 (28.06%) had no record of education. It was also noted that 573 (60.89%) had no form of health insurance.\u003c/p\u003e\n\u003cp\u003eThe study also showed that the Accident and Emergency Department, the Department of Medicine and Therapeutics, and the Surgery Department were the departments with the highest contributions to the DAMA patient numbers with 382 (40.59%), 169 (17.96%) and 167 (17.74%) respectively. The study also unearthed a higher intra-departmental prevalence rate than that of the hospital at the A\u0026amp;E department 3.26% and 2.25% at the Department of Medicine and Therapeutics. The other five (5) departments had lower prevalence rates compared to that of the hospital.\u003c/p\u003e\n\u003ch3\u003eConclusion\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eDischarge against medical advice is still a common issue that has an impact on hospital resources, the economy, and patient outcomes. Although a wide range of individuals are affected, those with particular traits and comorbidities appear to be more inclined to refuse medical advice and depart. While this issue has a variety of root causes, some universal approaches can be implemented to effectively mitigate patients\u0026apos; suffering discharge against medical advice, a structure designed to support and shield healthcare facilities and physicians in their efforts to preserve patients\u0026apos; health, particularly when they are faced with competing patients\u0026rsquo; family interests.\u003c/p\u003e\n\u003ch3\u003eLimitations of the Study\u003c/h3\u003e\n\u003cp\u003eThere is hardly any study without limitations and this study was no exception:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the first place, using data that has already been collected could not ensure the highest level of accuracy. Also, some variables that would have enriched the research were excluded because that data was not available on the patient records. These variables included the community and Region of residency and whether the patient came in as a referral from another hospital or not. Other variables had large numbers of patients with missing records that no meaningful or further analysis could be done.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Information on the demographics collected at the records point may be wrongly inputted and such variables cannot be detected since the patients are not available for verification.\u003c/p\u003e\n\u003cp\u003eFurthermore, the study was further limited by not including other \u0026lsquo;DAMA patients\u0026rsquo; who self-discharge from follow-up clinics and reviews after formal medical discharge from in-patient care. These reviews are technically part of management but many fail to comply since they are mostly stable and not acutely ill. They do not officially inform the hospital of this discontinuation of care and are therefore a DAMA group that are overlooked.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;However, these limitations were not significant enough to affect the findings of the study.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eA\u0026amp;E \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Accident and Emergency \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAIDS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Acquired Immune Deficiency Syndrome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAMA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Against Medical Advice \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDAMA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Discharge Against Medical Advice\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eED \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Emergency Department\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFBH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Faith-Based Healing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFGDs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Focused Group Discussions\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGDP \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Gross Domestic Product \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGHS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ghana Health Service\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGSS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ghana Statistical Service \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGMS \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ghana Metrological Service \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eICU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Intensive Care Unit \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHIV \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Human Immunodeficiency Virus\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLAMA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Leave Against Medical Advice\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMIC \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Low- and Middle-income countries \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMMDAs \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Metropolitan Municipal District Assemblies\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMOH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ministry of Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNICU \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Neonatal Intensive Care Unit \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOPD \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Out-Patient Department\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRTA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Road Traffic Accident\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTTH \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Tamale Teaching Hospital\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUK \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; United Kingdom\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUSA \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; United States of America \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; World Health Organisation\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFirst off, written permission was obtained from the TTH Research Directorate with reference number TTH/R\u0026amp;D/SR/298 dated 16\u003csup\u003eth\u003c/sup\u003e October 2023. This permission letter was used to apply for ethical approval for the study and also copied to the departments of the hospital to enable the research work to proceed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST) before data collection. The ethical approval number CHRPE/AP/1021/23 dated 16\u003csup\u003eth\u003c/sup\u003e November, 2023. This ethical approval was valid for a year, between 16\u003csup\u003eth\u003c/sup\u003e November, 2023 to 15\u003csup\u003eth\u003c/sup\u003e November, 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research adhered to the Declaration of Helsinki on which bases ethical approval was given. Find in supplementary file 1.\u003c/p\u003e\n\u003cp\u003eAdditionally, the permission letter from TTH R\u0026amp;D and the ethical approval was copied to the various departments of TTH to inform the departmental management.\u003c/p\u003e\n\u003cp\u003eAnonymity was achieved by removing the names and hospital identification numbers of the patients during the cleaning of the data for analysis. They were initially included to enable easy identification of patients for cross checking of the data and for the second part of the study which is not reported here. This were phone call in-depth interview to ensure DAMA patients or relatives were actually interviewed.\u003c/p\u003e\n\u003ch3\u003eInformed consent\u003c/h3\u003e\n\u003cp\u003eThere were no individual consent forms signed by DAMA patients since it was a retrospective study. Nonetheless, ethical approval was obtained from the Institutional Review Board (IRB) of the Kwame Nkrumah University of Science and Technology (KNUST). The ethical approval number CHRPE/AP/1021/23, dated 16\u003csup\u003eth\u003c/sup\u003e November, 2023, enabled data extraction without individual consent from the already discharged patients. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from Tamale Teaching Hospital patient eFolders but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the research department of Tamale Teaching Hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt was funded by the corresponding author\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Akagwire David (MD) \u0026ndash; conceptualisation, data collecting, analysis, administration, writing \u0026ndash; original draft (lead)\u003c/p\u003e\n\u003cp\u003eEsther Terkour Padi \u0026nbsp;\u0026ndash;, writing \u0026ndash; original draft, writing \u0026ndash; review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVivian Kapio Abem (PhD)\u0026ndash; Supervision, writing - review and editing\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI want to thank the management and staff of Tamale Teaching Hospital for their generous support throughout this research. My special thanks go to the head and staff of the records department for helping me with the extraction of the secondary data especially. \u0026nbsp;God bless you all.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAbbani, A. Y., Sawangdee, Y., Omisakin, O. A., \u0026amp; Maretalinia, M. (2023). Socio-Demographic Determinants of Non-Utilisation of Antenatal Care Services by Women in the Northern Region of Nigeria. \u003cem\u003eJournal of Health Research\u003c/em\u003e, \u003cem\u003e37\u003c/em\u003e(3). https://doi.org/10.56808/2586940X.1043\u003c/li\u003e\n \u003cli\u003eAbuzeyad, F. H., Farooq, M., Alam, S. F., Ibrahim, M. I., Bashmi, L., Aljawder, S. S., Ellouze, N., Almusalam, A., Hsu, S., \u0026amp; Das, P. (2021). 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Looking to improve your practice? consider the science of quality improvement to get started. \u003cem\u003eJournal of Athletic Training\u003c/em\u003e, \u003cem\u003e55\u003c/em\u003e(11), 1137\u0026ndash;1141. https://doi.org/10.4085/1062-6050-0342.19\u003c/li\u003e\n \u003cli\u003eWILMER, H. A. (1955). The tuberculosis patient who leaves against medical advice from the San Francisco City and County Hospital. \u003cem\u003eDiseases of the Chest\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(6). https://doi.org/10.1378/chest.27.6.597\u003c/li\u003e\n \u003cli\u003eYong, T. Y., Fok, J. S., Hakendorf, P., Ben-Tovim, D., Thompson, C. H., \u0026amp; Li, J. Y. (2013). Characteristics and outcomes of discharges against medical advice among hospitalised patients. \u003cem\u003eInternal Medicine Journal\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(7), 798\u0026ndash;802. https://doi.org/https://doi.org/10.1111/imj.12109\u003c/li\u003e\n \u003cli\u003eYusuf, M. B., Ogunlusi, J. D., Popoola, S. O., Ogunlayi, S. O., Babalola, W. O., \u0026amp; Oluwadiya, K. S. (2017). Self-discharge against medical advice from tertiary health institution: A call for concern. \u003cem\u003eThe Nigerian Postgraduate Medical Journal\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(3). https://doi.org/10.4103/npmj.npmj_88_17\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Discharge against medical advice, leave against medical advice, Against medical advice","lastPublishedDoi":"10.21203/rs.3.rs-6761858/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6761858/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDischarge Against Medical Advice (DAMA) is a phenomenon where patients seek to terminate treatment against the advice of healthcare giver. Globally, DAMA represents a complex issue within healthcare systems, posing challenges to patients and healthcare providers. Generally, DAMA patients are at a higher risk for complications, re-admissions, increased healthcare costs, disability, longer rehabilitation and higher mortality. They are potentially a source of disease spread in communities and public. This study aimed to characterise the DAMA patients from a major referral facility, its prevalence at the hospital and departmental level.\u003c/p\u003e \u003cp\u003eA retrospective descriptive cross-sectional design using quantitative method. Secondary data of 941 DAMA patients between December 1, 2020, to June 31, 2023, were extracted.\u003c/p\u003e \u003cp\u003eDAMA patients (n\u0026thinsp;=\u0026thinsp;941) showed an overall hospital prevalence rate of 1.75%. Accident and Emergency had a prevalence of 3.26%, followed by a prevalence rate of 2.25% at the Medicine and Therapeutics department. The polyclinic department recorded a prevalence rate of 1.72%, then the Department of Surgery followed closely with a prevalence rate of 1.54%. A low prevalence rate of 0.86% was obtained at the Department of Obstetrics and Gynecology while the paediatric department closely followed with a lower prevalence rate of 0.80. The dental department recorded no case. The majority of cases were male, 667 (70.88%). The majority of the patients; 650 (69.08%) were in the economically productive age group (between the ages of 20 to 61 years). Furthermore, 278 (29.54%) of patients had no form of formal education while 397 (42.19%) patients had some level of formal education. The majority 573 (60.89%) of patients who took DAMA had no form of health insurance. In addition, 144 (15.30%) of the patients were single while 241 (25.61%) were identified as married. Also, 506 (53.77%) of the patients belonged to the Islamic religion, 203 (21.57%) Christian and 16 (1.70%) of the patients practised African traditional religion. As many as 289 (30.71%) had no record of their employment status. Employed and unemployed had a total of 232 (24.65%) and 215 (22.84%) respectively.\u003c/p\u003e \u003cp\u003eThe hospital will utilize this knowledge to empower and encourage the records department of TTH to encourage its staff to endeavour to ensure complete data of the patient to be taken to further enable full analysis in future studies.\u003c/p\u003e","manuscriptTitle":"Discharge Against Medical Advice From the Tamale Teaching Hospital: Who Is Involved, the Prevalence and Departmental Differences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 11:23:13","doi":"10.21203/rs.3.rs-6761858/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f3af7d9c-3950-4f7a-87c4-6c99ac9e8243","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-17T07:28:01+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-10 11:23:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6761858","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6761858","identity":"rs-6761858","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}