Browsing by Author "Jackson, E.F."

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Being ready, willing and able: understanding the dynamics of family planning decision-making through community-based group discussions in the Northern Region, Ghana
(Genus, 2021) Biney, A.A.E.; Wright, K.J.; Kushitor, M.K.; Jackson, E.F.; Philips, J.F.; Awoonor-Williams, J.K.; Bawa, A.A.
Regional contraceptive use differentials are pronounced in Ghana, with the lowest levels occurring in the Northern Region. Community-based health services, intended to promote maternal and child health and family planning use, may have failed to address this problem. This paper presents an analysis of qualitative data on community perspectives on family planning “readiness,” “willingness,” and “ability” compiled in the course of 20 focus group discussions with residents (mothers and fathers of children under five, young boys and girls, and community elders) of two communities each in two Northern Region districts that were either equipped with or lacking direct access to community health services. The study districts are localities where contraceptive use is uncommon and fertility is exceptionally high. Results suggest that direct access to community services has had no impact on contraceptive attitudes or practice. Widespread method knowledge is often offset by side-effect misperceptions. Social constraints are prominent owing to opposition from men. Findings attest to the need to improve the provision of contraceptive information and expand method choice options. Because societal acceptance and access in this patriarchal setting is critical to use, frontline worker deployment should prioritize strategies for outreach to men and community groups with prominent attention to social mobilization themes and strategies that support family planning
Being ready, willing and able: understanding the dynamics of family planning decision-making through community-based group discussions in the Northern Region, Ghana
(Genus, 2021) Biney, A.A.E.; Wright, K.J.; Kushitor, M.K.; Jackson, E.F.; Phillips, J.F.; Awoonor-Williams, J.K.; Bawah, A.A.
Regional contraceptive use differentials are pronounced in Ghana, with the lowest levels occurring in the Northern Region. Community-based health services, intended to promote maternal and child health and family planning use, may have failed to address this problem. This paper presents an analysis of qualitative data on community perspectives on family planning “readiness,” “willingness,” and “ability” compiled in the course of 20 focus group discussions with residents (mothers and fathers of children under five, young boys and girls, and community elders) of two communities each in two Northern Region districts that were either equipped with or lacking direct access to community health services. The study districts are localities where contraceptive use is uncommon and fertility is exceptionally high. Results suggest that direct access to community services has had no impact on contraceptive attitudes or practice. Widespread method knowledge is often offset by side-effect misperceptions. Social constraints are prominent owing to opposition from men. Findings attest to the need to improve the provision of contraceptive information and expand method choice options. Because societal acceptance and access in this patriarchal setting is critical to use, frontline worker deployment should prioritize strategies for outreach to men and community groups with prominent attention to social mobilization themes and strategies that support family planning.
The child survival impact of the Ghana Essential Health Interventions Program: A health systems strengthening plausibility trial in Northern Ghana
(PLoS ONE, 2019-05-23) Bawah, A.A.; Awoonor-Williams, J.K.; Asuming, P.O.; Jackson, E.F.; Boyer, C.B.; Kanmiki, E.W.; Achana, S.F.; Akazil, J.; Phillips, J.F.
Background The Ghana Health Service in collaboration with partner institutions implemented a five-year primary health systems strengthening program known as the Ghana Essential Health Intervention Program (GEHIP). GEHIP was a plausibility trial implemented in an impoverished region of northern Ghana around the World Health Organizations (WHO) six pillars combined with community engagement, leadership development and grassroots political support, the program organized a program of training and action focused on strategies for saving newborn lives and community-engaged emergency referral services. This paper analyzes the effect of the GEHIP program on child survival. Methods Birth history data assembled from baseline and endline surveys are used to assess the hazard of child mortality in GEHIP treatment and comparison areas prior to and after the start of treatment. Difference-in-differences (DiD) methods are used to compare mortality change over time among children exposed to GEHIP relative to children in the comparison area over the same time period. Models test the hypothesis that a package of systems strengthening activities improved childhood survival. Models adjusted for the potentially confounding effects of baseline differentials, secular mortality trends, household characteristics such as relative wealth and parental educational attainment, and geographic accessibility of clinical care. Results The GEHIP combination of health systems strengthening activities reduced neonatal mortality by approximately one half (HR = 0.52, 95% CI = 0.28,0.98, p = 0.045). There was a nullincremental effect of GEHIP on mortality of post-neonate infants (from 1 to 12 months old) (HR = 0.72; 95% CI = 0.30,1.79; p = 0.480) and post-infants (from 1 year to 5 years old) -(HR = 1.02; 95% CI = 0.55–1.90; p = 0.940). Age-specific analyses show that impact was concentrated among neonates. However, effect ratios for post-infancy were inefficiently assessed owing to extensive survival history censoring for the later months of childhood. Children were observed only rarely for periods over 40 months of age. Conclusion GEHIP results show that a comprehensive approach to newborn care is feasible, if care is augmented by community-based nurses. It supports the assertion that if appropriate mechanisms are put in place to enable the various pillars of the health system as espoused by WHO in rural impoverished settings where childhood mortality is high, it could lead to accelerated reductions in mortality thereby increasing survival of children. Policy implications of the pronounced neonatal effect of GEHIP merit national review for possible scale-up.
Does the provision of community health services offset the effects of poverty and low maternal educational attainment on childhood mortality? An analysis of the equity effect of the Navrongo experiment in Northern Ghana
(SSM - Population Health, 2019-04) Bawah, A.A.; Phillips, J.F.; Asuming, P.O.; Jackson, E.F.; Walega, P.; Kanmiki, E.W.; Sheff, M.C.; Oduro, A.
The Government of Ghana has instituted a National Poverty Reduction Program with an initiative known as the Community-based Health Planning and Services (CHPS) as its core health development strategy. CHPS was derived from a plausibility trial of the Navrongo Health Research Centre testing four contrasting primary health care strategies: i) Training unpaid volunteers to promote health in communities, ii) placing nurses in communities with training and supplies for treating childhood illnesses, iii) combining the nurse and volunteer approaches, and iv) sustaining a comparison condition whereby clinic services were provided without community resident workers. This paper presents an age-conditional proportional hazard analysis of the long term impact of community health worker exposure among 94,599 children who were ever under age five over the January 1, 1995 to December 2010 period, adjusting for age conditional effects of shifts in exposure type as CHPS was scaled up in Navrongo project area over the 1995–2000 period. Results show that children whose parents are uneducated and relatively poor experience significantly higher mortality risks than children of the educated and less poor. Conditional hazard regression models assess the impact of CHPS on health equity by estimating the interaction of equity indicators with household exposure to CHPS service operations, adjusting for age conditional exposure to original Community Health and Family Planning Project (CHFP) service strategies as scale-up progressed. The association of mortality risk among children with uneducated and relatively impoverished mothers is offset by exposure to community health nursing services. If exposure is limited to volunteer-provided services alone, survival benefits arise only among children of relatively advantaged households. Findings lend support to policies that promote the CHPS nurse approach to community-based services as a core health component of poverty reduction programs.
The impact of the Navrongo Project on contraceptive knowledge and use, reproductive preferences, and fertility
(Studies in Family Planning, 2002-06) Debpuur, C.; Phillips, J.F.; Jackson, E.F.; Nazzar, A.; Ngom, P.; Binka, F.N.
The Navrongo Community Health and Family Planning Project is a quasi-experimental study designed to test the hypothesis that introducing health and family planning services in a traditional African societal setting will introduce reproductive change. This article presents the impact of the initial three years of project exposure on contraceptive knowledge, awareness of supply sources, reproductive preferences, contraceptive use, and fertility. Findings show that knowledge of methods and supply sources increased as a result of exposure to project activities and that deployment of nurses to communities was associated with the emergence of preferences to limit childbearing. Fertility impact is evident in all treatment cells, most prominently in areas where nurse-outreach activities are combined with strategies for involving traditional leaders and male volunteers in promoting the program. In this combined cell, the initial three years of project exposure reduced the total fertility rate by one birth, comprising a 15 percent fertility decline relative to fertility levels in comparison communities.
Inconsistent reporting of female genital cutting status in northern Ghana: Explanatory factors and analytical consequences
(2003-09) Jackson, E.F.; Akweongo, P.; Sakeah, E.; Hodgson, A.; Asuru, R.; Phillips, J.F.
Although many cross-sectional social surveys have included questions about female genital cutting status and correlated personal characteristics, no longitudinal studies have been launched that permit investigation of response biases associated with such surveys. This study draws upon the findings of a longitudinal study of women aged 15 to 49 in rural northern Ghana. The self-reported circumcision status of women interviewed in 1995 was compared with the status they reported when they were interviewed again in 2000 after the government began enforcing a law banning the practice and public information campaigns against it were launched. In all, 13 percent of respondents who reported in 1995 that they had been circumcised stated that they had not been circumcised in the 2000 reinterview; this inconsistency reached 50 percent for the youngest age group. Analysis shows that women who said they had not been circumcised are significantly younger, more likely to be educated, and less likely to practice traditional religion than are women who reported that they were circumcised. Factors that may explain these correlates of denial are discussed, and implications for research are reviewed.
It’s a woman’s thing: gender roles sustaining the practice of female genital mutilation among the Kassena‑Nankana of northern Ghana
(Reproductive Health, 2021) Akweongo, P.; Jackson, E.F.; Shirley Appiah‑Yeboah, S.; Sakeah, E.; Phillips, J.F.
Introduction: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women’s empowerment and changing gender roles. Methods: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. Results: The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. Conclusion: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women’s social networks for offsetting their extended family familial roles in sustaining FGM/C practices
It’s a woman’s thing: gender roles sustaining the practice of female genital mutilation among the Kassena‑Nankana of northern Ghana
(Reproductive Health, 2021) Akweongo, P.; Jackson, E.F.; Appiah‑Yeboah, S.; Sakeah, E.; Phillips, J.F.
Introduction: The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women’s empowerment and changing gender roles. Methods: This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. Results: The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. Conclusion: Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women’s social networks for offsetting their extended family familial roles in sustaining FGM/C practices. Keywords: Female genital mutilation, Female genital cutting, Social determinants, Gender stratification, Ghana, Sahelian Africa, Harmful traditional practices
The long-term fertility impact of the navrongo project in northern Ghana
(2012-09) Phillips, J.F.; Jackson, E.F.; Bawah, A.A.; Macleod, B.; Adongo, P.; Baynes, C.; Williams, J.
This study assesses the long-term fertility impact of the Community Health and Family Planning Project of the Navrongo Health Research Centre in Ghana and addresses policy debates concerning the role of family planning programs in rural Africa. Conducted in a remote traditional area on Ghana's northern border, the study tests the hypothesis that convenient family planning service delivery can induce and sustain reproductive change in a societal context that would not be expected to foster demographic transition. By 1999, results indicated that significant fertility decline arose in the early years of the project, associated with the combination of services provided by community nurses and social mobilization activities focused on men. When project strategies were scaled up, social mobilization components were neglected. As a consequence, the long-term impact of scaled-up operations was negligible. Results suggest that initial effects met the need for child spacing without introducing a sustained demographic transition. © 2012 The Population Council, Inc.
Measuring Health Systems Strength and Its Impact: Experiences from the African Health Initiative
(BMC Health Services Research, 2017-12) Sherr, K.; Fernandes, Q.; Kanté, A.M.; Bawah, A.; Condo, J.; Mutale, W.; Hingora, A.; Mboya, D.; Exavery, A.; Tani, K.; Manzi, F.; Pemba, S.; Phillips, J.; Kante, A.M.; Ramsey, K.; Baynes, C.; Awoonor-Williams, J.K.; Nimako, B.A.; Kanlisi, N.; Jackson, E.F.; Sheff, M.C.; Kyei, P.; Asuming, P.O.; Biney, A.,; Chilengi, R.; Ayles, H.; Mwanza, M.; Chirwa, C.; Stringer, J.; Mulenga, M.; Musatwe, D.; Chisala, M.; Lemba, M.; Drobac, P.; Rwabukwisi, F.C.; Hirschhorn, L.R.; Binagwaho, A.; Gupta, N.; Nkikabahizi, F.; Manzi, A.; Farmer, D.B.; Hedt-Gauthier, B.; Cuembelo, F.; Michel, C.; Gimbel, S.; Wagenaar, B.; Henley, C.; Kariaganis, M.; Manuel, J.L.; Napua, M.; Pio, A.
Background: Health systems are essential platforms for accessible, quality health services, and population health improvements. Global health initiatives have dramatically increased health resources; however, funding to strengthen health systems has not increased commensurately, partially due to concerns about health system complexity and evidence gaps demonstrating health outcome improvements. In 2009, the African Health Initiative of the Doris Duke Charitable Foundation began supporting Population Health Implementation and Training Partnership projects in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze significant advances in strengthening health systems. This manuscript reflects on the experience of establishing an evaluation framework to measure health systems strength, and associate measures with health outcomes, as part of this Initiative. Methods: Using the World Health Organization's health systems building block framework, the Partnerships present novel approaches to measure health systems building blocks and summarize data across and within building blocks to facilitate analytic procedures. Three Partnerships developed summary measures spanning the building blocks using principal component analysis (Ghana and Tanzania) or the balanced scorecard (Zambia). Other Partnerships developed summary measures to simplify multiple indicators within individual building blocks, including health information systems (Mozambique), and service delivery (Rwanda). At the end of the project intervention period, one to two key informants from each Partnership's leadership team were asked to list - in rank order - the importance of the six building blocks in relation to their intervention. Results: Though there were differences across Partnerships, service delivery and information systems were reported to be the most common focus of interventions, followed by health workforce and leadership and governance. Medical products, vaccines and technologies, and health financing, were the building blocks reported to be of lower focus. Conclusion: The African Health Initiative experience furthers the science of evaluation for health systems strengthening, highlighting areas for further methodological development - including the development of valid, feasible measures sensitive to interventions in multiple contexts (particularly in leadership and governance) and describing interactions across building blocks; in developing summary statistics to facilitate testing intervention effects on health systems and associations with health status; and designing appropriate analytic models for complex, multi-level open health systems.
Research Capacity Building Integrated into PHIT Projects: Leveraging Research and Research Funding to Build National Capacity
(BMC Health Services Research, 2017-12) Hedt-Gauthier, B.L.; Chilengi, R.; Jackson, E.; Michel, C.; Napua, M.; Odhiambo, J.; Bawah, A.; Hingora, A.; Mboya, D.; Exavery, A.; Tani, K.; Manzi, F.; Pemba, S.; Phillips, J.; Kante, A.M.; Ramsey, K.; Baynes, C.; Awoonor-Williams, J.K.; Nimako, B.A.; Kanlisi, N.; Jackson, E.F.; Sheff, M.C.; Kyei, P.; Asuming, P.O.; Biney, A.; Ayles, H.; Mwanza, M.; Chirwa, C.; Stringer, J.; Mulenga, M.; Musatwe, D.; Chisala, M.; Lemba, M.; Mutale, W.; Drobac, P.; Cyamatare Rwabukwisi, F.; Hirschhorn, L.R.; Binagwaho, A.; Gupta, N.; Nkikabahizi, F.; Manzi, A.; Condo, J.; Farmer, D.B.; Sherr, K.; Cuembelo, F.; Michel, C.; Gimbel, S.; Wagenaar, B.; Henley, C.; Kariaganis, M.; Manuel, J.L.; Pio, A.
ackground: Inadequate research capacity impedes the development of evidence-based health programming in sub-Saharan Africa. However, funding for research capacity building (RCB) is often insufficient and restricted, limiting institutions' ability to address current RCB needs. The Doris Duke Charitable Foundation's African Health Initiative (AHI) funded Population Health Implementation and Training (PHIT) partnership projects in five African countries (Ghana, Mozambique, Rwanda, Tanzania and Zambia) to implement health systems strengthening initiatives inclusive of RCB. Methods: Using Cooke's framework for RCB, RCB activity leaders from each country reported on RCB priorities, activities, program metrics, ongoing challenges and solutions. These were synthesized by the authorship team, identifying common challenges and lessons learned. Results: For most countries, each of the RCB domains from Cooke's framework was a high priority. In about half of the countries, domain specific activities happened prior to PHIT. During PHIT, specific RCB activities varied across countries. However, all five countries used AHI funding to improve research administrative support and infrastructure, implement research trainings and support mentorship activities and research dissemination. While outcomes data were not systematically collected, countries reported holding 54 research trainings, forming 56 mentor-mentee relationships, training 201 individuals and awarding 22 PhD and Masters-level scholarships. Over the 5 years, 116 manuscripts were developed. Of the 59 manuscripts published in peer-reviewed journals, 29 had national first authors and 18 had national senior authors. Trainees participated in 99 conferences and projects held 37 forums with policy makers to facilitate research translation into policy. Conclusion: All five PHIT projects strongly reported an increase in RCB activities and commended the Doris Duke Charitable Foundation for prioritizing RCB, funding RCB at adequate levels and time frames and for allowing flexibility in funding so that each project could implement activities according to their trainees' needs. As a result, many common challenges for RCB, such as adequate resources and local and international institutional support, were not identified as major challenges for these projects. Overall recommendations are for funders to provide adequate and flexible funding for RCB activities and for institutions to offer a spectrum of RCB activities to enable continued growth, provide adequate mentorship for trainees and systematically monitor RCB activities.
Respondents' Exposure to Community-based Services and Reported Fertility-Regulation Behavior: A Decade of Data from the Navrongo Community Health and Family Planning Project
(2016) Jackson, E.F.; Bawah, A.A.; Williams, J.E.; Phillips, J.F.
This article examines a decade of demographic surveillance data from rural northern Ghana linked with prospective panel survey data recording respondents' reported fertility-regulation behavior. We assess the impact of access to community-based contraceptive services, reported fertility-regulation behavior, and their interaction on the risk of a conception that results in a birth. The effects of service exposure differ by marital status. Reported use of any method to delay or avoid pregnancy appears to be more effective in reducing the risk of conception among the unmarried in areas offering community-based contraceptive services, relative to those in areas where services are facility based. Among both married and unmarried survey respondents who state that they are not using contraception, the risk of conception is lower among women in areas with community-based services than among women in communities without these services. The lower risk of conception among women who are receiving community-based services and who report that they are regulating their fertility may be due to increased efficacy and duration of fertility regulation. Among women who report that they are not regulating their fertility, under-reporting of contraceptive use in experimental areas is likely to play a role in explaining these findings.
Spatial and Socio-demographic determinants of contraceptive use in the Upper East region of Ghana
(2015) Achana, F.S.; Bawah, A.A.; Jackson, E.F.; Welaga, P.; Awine, T.; Asuo-Mante, M.; Oduro, A.R.; Awoonor-Williams, J.K.; Philips, J.F.
Background This paper presents results of baseline data on the determinants of contraceptive use in 7 districts in northern Ghana where there is an ongoing integrated primary health care systems strengthening projectknown as the Ghana Essential Health Intervention Project (GEHIP). Methods We used a household survey data conducted within 66 randomly sampled census enumeration areas in seven rural districts of the Upper East Region of northern Ghana where health systems strengthening interventions are currently ongoing in three of the districts with four of the districts serving as comparison districts. This survey was conducted prior to the introduction of interventions. Data was collected on various indices included geographic information systems (GIS) and contraceptive use. The data was analyzed using survey design techniques that accounts for correct variance estimation. Categorical variables were summarized as proportions and associations between these variables and contraceptive use tested using Chi-square test. Uni-variable and multivariable logistic regression techniques were used to assess the effects of the selected covariates on contraceptive use. All tests were deemed to be statistically significant at 5% level statistical significance. Results Results show that contraceptive use is generally low (about 13 per cent) and use is nearly evenly for spacing and stopping purposes. Factors associated with the use of contraceptives include exposure to integrated primary healthcare services, the level of education, and socioeconomic status, couple fertility preference, marital status, and parity. For instance, the odds of contraceptive use among 15–45 year old women who live 2 km or more from a CHPS compound is 0.74 compared to women who live less than 2 km from a CHPS compound (p-value = 0.035). Conclusion The findings suggest that rapid scale up of the Community based Health Planning and Services (CHPS) program accompanied with improved door-to-door health services would kindle uptake of modern contraceptive use, reduce unwanted pregnancies and hasten the attainment of MDG 4 & 5 in Ghana. Keywords: Spatial, Social determinants, Contraceptive use, Family planning, Primary care, Women, Ghana
What do you do with success? the science of scaling up a health systems strengthening intervention in Ghana
(BioMed Central Ltd., 2018) Phillips, J.F.; Awoonor-Williams, J.K.; Bawah, A.A.; Nimako, B.A.; Kanlisi, N.S.; Sheff, M.C.; Asuming, P.O.; Kyei, P.E.; Biney, A.; Jackson, E.F.
Background: The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+). Methods: A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process. Discussion: A process of exchanges, team interaction, and catalytic financing has accelerated the expansion of community-based primary health care in Ghana's Upper East Region (UER). Using two Northern and two Volta Region districts, the UER systems learning concept will be transferred to counterpart districts where a program of team-based peer training will be instituted. A mixed method research system will be used to assess the impact of this transfer of innovation in collaboration with national and regional program management. This arrangement will generate embedded science that optimizes prospects that results will contribute to national CHPS reform policies and action. © 2018 The Author(s).