Department of Population, Family and Reproductive Health
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Item Sexual Communication Within Families And Influence On Sexual Behaviour And Contraception Among Young People In The Brong Ahafo Region(University of Ghana, 2011-12) Manu, A.ABackground: Young people aged 10-24 years represent a significant proportion of the Ghanaian population. Many are sexually active and are at considerable risk of negative health outcomes due to lack of adequate sexual and reproductive health knowledge. Although growing international evidence suggests that parent-child communication about sex has significant positive influence on young people’s sexual behaviours, this subject has been poorly explored among Ghanaian families. Little is known about how sexual communication transpires, its determinants and the types of topics parents talk about when they engage their children in sexual discussion. Knowing the predictors of parental sexual communication, nature and the extent to which sexual communication influences young people’s sexual behaviours are important for any intervention to reduce sexual risk behaviours among young people. Objective: To explore the relationship between parental sexual communication and young people’s sexual behaviours and contraception in the Brong Ahafo region of Ghana. Methods: A cross-sectional design was used to sample 823 parent-child dyads through a two-stage systematic sampling technique with probability proportional to size. Interviewer-administered questionnaire method was used to gather quantitative data on parent-child communication and sexual behaviour. Twenty specific sexual topics categorized into biological/physical development, sexual risk prevention and experiential sex were investigated to describe the patterns, contents and frequency of communication. Congruence between parent and child reports about whether sexual discussions had occurred was also examined. The Pearson’s chi-square and hierarchical multiple regression techniques were utilized to analyse sexual topics and predictors of parental communications respectively. In-depth interviews were used collect qualitative data to flesh-out relevant issues that standard questionnaire could not cover satisfactorily. Results: Mean (SD) age of young people was 16.9 (4.0) years and 47.3(10.1) years for parents. Majority (74.4%) of parents had ever discussed sexual issues with their children. Mothers communicate more to children than fathers. Discussions centred on sexual risk prevention topics, including sexual abstinence, HIV/AIDS, STDs, puberty, menstruation, physical development, premarital sex, and substance use. Parents discussed different sexual topics at different child ages. About 43% (50% females and 36% males) of young people reported being sexually active, of which 65% had had multiple sexual partnerships. Young men were two times more likely than young women to have engaged multiple sex partners; odds ratio (95% confidence interval) = 1.9 (1.22 – 3.06). Multiple logistic regression revealed that family religiosity, parental sexual knowledge, parent discipline and parental trustworthiness increase the odds of parents discussing sexual issues with their children. Additionally, on-time communication (sexual discussion occurring before a child initiates sex) appeared to be protective against sexual activities. Conclusions: Parent-child sexual communication promises to be an important medium to effect protective behaviours and behavioural change among young people. Educational interventions for parents could enable parents to communicate more effectively with their children for healthy development.Item Parent Training and Parent-Adolescent Communication about Sexuality in Accra Metropolis, Ghana(University of Ghana, 2014-07) Baku, E.A; Sally-Ann, O.; Laar, A.K.; Adanu, R.M.; University of Ghana, College of Health Sciences , School of Public Health , Department of Population, Family and Reproductive HealthBackground: Talking about sexual issues with children is a difficult task for most parents. This is because most parents are not trained to talk to their children about sexual issues. Many parents also lack the knowledge and skills to talk to their children about sexual issues. Evidence shows that intervention studies that trained parents on how to communicate with their children about sexuality have shown positive results. Training parents to talk to their adolescents about sexual issues will reduce sexual risk behaviours among adolescents and young people. Objective: To assess the effects of training parents on parent-adolescent communication about sexuality in the Accra Metropolis, Ghana. Methods: An intervention study which consisted of 138 parent-adolescent pairs from 12 public Junior High Schools in two sub-metropolises in the Accra Metropolis answered baseline survey on parent-adolescent communication on sexual topics and were put into intervention and control groups (intervention group, 73 parent-adolescent pairs in 6 schools; control group, 72 parent-adolescent pairs in 6 schools). Parents and adolescents completed a follow up survey of questionnaires on parent-adolescent discussion about sexual topics three months after the programme. Results: The proportion of parents with very good knowledge increased more in the intervention group (37.0% to 60.0%) than the control group (27.7% to 34.7%). After the training, the parents in the intervention group (30.1% to 82.9%) had better attitudes towards adolescents’ use of reproductive health services than the control group. The proportion of parents in the intervention group who ever discussed sexual topics with their sons increased (60.3% to 88.6%) after the training. Most parents in both in the intervention (54.4%) and control (51.4%) groups would like to start talking to their children about sexual issues when the child is between 10 and 12 years old after the intervention. Mothers discussed more sexual topics with adolescents on all the categories of sexual topics than fathers. Sexual discussions focused mostly on sexual risk protection and risky sexual topics. Conclusion: The training increased the parents’ knowledge about sexuality, their ability and frequency of discussing sexual topics with their children. The training also improved the parents’ attitudes towards adolescent sexual issues. Key words: Adolescents, parents, sexuality, intervention and communication.Item Moringa Oleifera Leaf Supplementation on Vitamin a Status of Children in Ada-East District of Ghana(University of Ghana, 2015-03) Glover-Amengor, M.; Nyarko, A.; Afari, E.; Aryeetey, R.; University of Ghana, College of Health Sciences School of Public Health Department of Population, Family and Reproductive HealthBackground Globally over 195 million pre-school children are vitamin A deficient, whilst in Ghana, it was estimated that 72 % of pre-school children are vitamin A deficient. Periodic administration of high dose vitamin A capsules is currently used as a prevention strategy, but this requires appropriate healthcare infrastructure and is donor dependent, hence may not be sustainable if donor support is withdrawn. Inadequate dietary intake of vitamin A-rich foods is a major etiological factor in vitamin A deficiency, so one other prevention strategy could be to promote the consumption of these foods. Plant-based foods such as orange-fleshed roots and tubers, fruits and dark green leafy vegetables like Moringa oleifera (M. oleifera) leaves are rich sources of pro-vitamin A carotenoids that could be beneficial to vulnerable populations in low socio-economic households who mostly derive their nutrition from plant sources. M. oleifera leaves have been reported to improve retinol levels in rats. However, there are only anecdotal reports on the ability of M. oleifera leaves to improve retinol levels in humans. There is the need therefore to conduct evidence-based research to assess the effect of M. oleifera leaves on retinol levels in humans. Objective The objective of the study was to assess the efficacy of M. oleifera leaf supplementation to improve the vitamin A status of children in Ada-East district of Ghana. Methods The interventional study was preceded by an assessment of dietary uses of M. oleifera leaves in Ada-East district through a community survey of mothers/caregivers aged 19 years and above, and an acceptability test of M. oleifera leaf-fortified dishes by children in Ada-East district. Thereafter, children aged 5-12 years were randomized to either receive or not receive dried M. oleifera leaves for 9 weeks in three local dishes. The Intervention group (n = 85) consumed M. oleifera leaf-fortified dishes at 0.2 g/kg body weight, three times a week, whilst the Control group (n = 85) consumed the same food without M. oleifera leaves. Vitamin A, haemoglobin, haematocrit, erythrocytes, mean corpuscular volume, kidney and liver chemistry, and infections were assessed at the beginning and end of study. Vitamin A was assessed by high performance liquid chromatography (HPLC). Red blood indices were assessed on EDTA whole blood samples in the laboratory using Sysmex KX - 21N, an automated haematology analyser. Kidney and liver chemistry were assessed with EliTech clinical systems kits. Results One hundred and eighty (79.7 %) of respondents use M. oleifera leaves as a food ingredient in the district, but on an irregular basis, while two hundred and twelve (93.8 %) said they would feed their children when requested to do so, because they learned the leaves would make the children strong. M. oleifera leaf-fortified dishes were also highly acceptable to the children. Leaf supplementation improved retinol levels in the Intervention group significantly (P < 0.05). Those with marginal vitamin A status (serum retinol < 0.7 μmol/l) at baseline showed significant increases at end of study. There was a significant positive association between vitamin A and haemoglobin in the Intervention group (P < 0.05), but not in the Control group. All markers of kidney and liver safety did not show any significant changes at end of study. Conclusion M. oleifera leaf supplementation was efficacious to improve the vitamin A status of children in Ada-East district of Ghana.Item Continuity and Fragmentation of Antenatal and Delivery Care in the Volta Region of Ghana(University Of Ghana, 2017-03) Dery, S.K.K.Maternal mortality has over the years remained a global health issue with most of the deaths occurring in sub-Saharan Africa. With skilled antenatal care (ANC), many of these deaths can be prevented and as such skilled ANC attendance and skilled delivery have become key global indicators for measuring maternal health programmes across the world. The World Health Organization, until recently (2016) had recommended a minimum of 4 antenatal visits for pregnant women without any medical condition and whose pregnancies were progressing smoothly. This has since been updated to a minimum of 8 ANC contacts for a positive pregnancy experience. Ghana, over the years has been improving on the skilled ANC and delivery indicators with the 2014 Ghana Demographic and Health Survey (GDHS) showing that 87% of the pregnant women received the minimum 4 ANC visits, an increase from the 69% in 2003 while skilled delivery increased from 46% in 2003 to 74% in 2014. However, what remained unanswered is whether these ANC visits were made to several health facilities or to a single facility. In addition, it is unclear whether some pregnant women change their ANC facilities during delivery considering that labour and delivery constitute a critical point in the fight against maternal mortality, since complications during labour and delivery account for most of the maternal deaths in Ghana. In addition, though evidence from other studies show that some pregnant women receive care from multiple facilities, the extent of continuity and fragmentation of care during pregnancy and childbirth have not been quantified in Ghana. This study therefore sought to measure the level of longitudinal continuity and fragmentation of care during pregnancy and childbirth in the Volta Region of Ghana. iv Using National Health Insurance claims data for 2013 in the Volta Region, all the ANC and obstetrics data from all the facilities for the various months were merged into one file, deliveries were identified and classified as cesarean section or vaginal delivery. Visits of all the women that delivered were extracted from the data. Five continuity of care (CoC) indices (MFPC, MMCI, CoC, SECON and PDC) were calculated for each pregnant woman. Extent of repeat visits to each facility (provider continuity) and repeat visits to facilities in a district (district continuity) were calculated to represent the average of the proportion of visits that a facility/district got for all the women who visited the facility/district compared to other facilities/districts that those same women visited. Client-sharing between facilities and districts were identified. Two facilities shared a pregnant woman during ANC if the woman moves from facility of previous visit to the other facility of subsequent visit. A woman is said to have fragmented her care during delivery if she delivers at a facility different from where she sought most of her antenatal care. Five different types of network graphs were constructed using Gephi to help visualize the fragmentation of care among facilities and districts during ANC and delivery. A total of 14,474 pregnant women with a total of 92,095 visits (average of 5 visits per woman) were included in the study with 15.1% delivering by cesarean section (CS). The median maternal age was 27 and those that had CS were slightly older with a median age of 29. Although hospitals constituted 13% of the facilities in the study, they accounted for 73% of all visits and 83% of all deliveries. About 58% of all the pregnant women had perfect CoC: maintaining only one facility throughout ANC and delivery. There were medium to high levels of CoC among the various CoC indices (MFPC: 0.82 ±0.25; MMCI: 0.86 ±0.20; COC: 0.76 ±0.30; SECON: 0.80 ±0.28; PDC: 0.68 ±0.41). In addition, 32% of all the women and v 78% of those that visited multiple facilities made less than three quarters of their visits to the most frequently visited facility. The average provider (facility) continuity and district continuity in the region were 67% and 81% respectively and varies by districts and type of provider. About 19% of all subsequent visits, 26% of all deliveries, 32% of all CS deliveries, 63% of all deliveries by women with multiple facilities, 73% of all CS deliveries by women with multiple facilities were fragmented among facilities. In addition, 15% of all deliveries (36% among those with multiple facilities) and 20% of all CS deliveries (45% among those with multiple facilities) were performed at facilities that the pregnant women did not receive any ANC services from. Nine percent (8.9) of all subsequent visits, 13% of all deliveries, 20% of all CS deliveries and 30.5% of all deliveries by women with multiple facilities were fragmented across districts. In addition, 51.6% of all deliveries performed at facilities that the pregnant women never received ANC services from were fragmented across districts. Despite the high levels of CoC among the pregnant women, there is high fragmentation during the critical period of labour and delivery among those who visited multiple facilities. This situation seems to be exacerbated by the fact that there is high preference for hospital delivery, resulting in high levels of fragmentation of care during delivery among the various care facilities and across districts in the region, and is even more profound in districts that do not have hospitals, with higher proportions of the women moving from these districts to other districts with hospitals for delivery services. There is therefore the need for concerted effort to guarantee continuity and coordination of care throughout the ANC and delivery period by requiring every pregnant woman to have a primary care provider who will be responsible and accountable for coordinating the care that she receives.Item Assessment of the Implementation of the Home Visiting Strategy: A Case Study of Maternal and New Born Health Care in the Ga South Municipality of Ghana(University Of Ghana, 2017-07) Chandi, M.G.Background: Home visiting has been the pivot of both the Primary Health Care (PHC) and currently the CHPS concepts in the Ghana Health Service; yet there is little information on how the home visit strategy improves maternal and new born health. This study aimed at assessing the implementation of the home visiting strategy and its effect on maternal and newborn health care in the Ga South Municipality in Ghana. Methods: A cross sectional study employing mixed methods approach was carried out. Four hundred and fifty three women were interviewed using a structured questionnaire. Four methods (desk review, observation, Key Informant Interviews, and two Focus Group Discussions) were used in the qualitative aspect. The quantitative data was analysed in SPSS version 22 using descriptive statistics for the background characteristics. Chi Square test was used to determine the association between ANC 4+ visits, Post natal coverage and the home visit strategy on one hand; and on the other, infection prevention and exclusive breastfeeding and the home visiting strategy. Nvivo version 11 was used to analyse the qualitative study. Triangulation of data from the quantitative and qualitative studies was done resulting in a synthesised and synergized document. Results: About 51% of respondents had not seen home visit service providers in their communities. All the respondents agreed that the heavy workload of the Community Health Officers (CHOs) makes it difficult for them to conduct home visiting. The social network of clients influenced responsiveness to home visiting services. Fifty seven percent of respondents felt socio economic status of clients do influence home visiting services but there was not enough statistical evidence to conclude. Geographical access and availability of social amenities did not statistically influence home visiting services. The home visiting strategy is more beneficial to neonates than to pregnant women Conclusion: There are intervening factors that influence home visiting service delivery. Ensuring the availability and managing the workload of service providers could enhance home visiting services. The social networks of clients are valuable resources home visit service providers need to take advantage of.Item A Study of Community Perceptions and Strategies to Improve Women’s Dietary Quality in Savelugu-Nanton District, Ghana(University Of Ghana, 2018-07) Sawudatu, Z.Background: The diets of women in reproductive age (WRA) are an important determinant of their health outcomes and quality of life especially in northern Ghana, where women’s diets remain persistently suboptimal. However, socio-cultural barriers, one of the multiple influences on WRA’s diets, are rarely addressed in existing interventions. This study identified the socio-cultural barriers to WRA achieving optimal diets, which, herein, represent beliefs, attitudes and actions that are derived from the existing native and emergent culture of the community and tested the feasibility of a community-based pilot intervention developed in consultation with the community to address these barriers. Methods: Socio-cultural barriers to women’s diets were identified and characterized through a qualitative study involving the exploration of the local food system, dietary knowledge, attitudes and practices at Yilkpene and Kpachilo. Data was collected through key informant interviews, focus group discussions, qualitative 24-hour dietary recalls with in-depth interviews and observations at the household and community levels. A 17-week attitudinal and behaviour change intervention was designed and implemented at Yilkpene in consultation with key community stakeholders. The first component, nutrition education, emphasized the importance of women’s diets and their reproductive health. The second component, advocacy, concerned empowering women to have more control over household food resources and modifying food taboos affecting women. Messages were delivered in the local language through participatory activities including community durbars, small group meetings, home-visits and food demonstration sessions. In the post-evaluation of the intervention, data was collected from 182 participants using the same tools used at baseline. The two sets of data were compared to assess the impact of the intervention at Yilkpene. Results: Study participants, all aged at least 15 years, were mostly WRA (73%), married Muslims (87.4%) without formal education whose source of livelihood was farming (84.1%) and had households with sizes ranging between 6 and 40. At baseline, gender and socio-cultural factors significantly influenced all aspects of the food system, limiting women’s access to quality foods. Animal-source food taboos, which are mostly gender-based and affect the quality of women’s diets, were identified. At endline, these practices did not change but members of Yilkpene community were sensitized about them. Prior to the intervention, the dietary knowledge and attitudes among members of both communities were sub-optimal; but, at endline, improved knowledge and attitudes were observed in both communities even though the scope of improvements was more in the intervention community. There were also less reported beliefs about plant-source food restrictions at Yilkpene compared to Kpachilo. At baseline, close to half (45%) of women in either community could not meet their minimum dietary diversity but diversity deficit declined at endline (25% at Yilkpene and 10% at Kpachilo). Conclusion: Attitudinal and behavioural change communication interventions on entrenched socio-cultural issues pertaining to women’s diets need more prolonged and sustained durations to enhance their scopes of feasibility. Ghana Health Service and individuals should organize similar interventions.Item Factors of Rapid Repeat Pregnancy and Its Consequences on Depression among Adolescents in the Greater Accra Region, Ghana.(University Of Ghana, 2018-07) Amuasi, S.A.Rapid repeat pregnancy (RRP) is defined as pregnancy onset within 24 months of the previous pregnancy outcome. RRP has been identified to result from different situations and as such might create different risks to the individual. Several studies have shown an association between RRP and mental health issues such as anxiety, emotional stress, depression, aggression and poorer education attainment. There is a pint-size consensus as to which risk factors are the very key predictors of RRP and whether the outcome (RRP) may lead to depression. This study seeks to identify the main risk factors that could lead to RRP and its consequences on depression among adolescents. METHODS: A mixed method approach (quantitative and qualitative) was used for this study which was conducted in 12 public health facilities in the Greater Accra Region. An unmatched case-control study design was used for the study. The cases were adolescent girls aged between 15 and 19 years who have had more than one pregnancy within two years. Controls were adolescent girls aged between 15 and 19 years who have had one pregnancy which either ended an abortion or delivery with more than twenty-four months spacing. The sample size for the quantitative method was n= 417 with 209 controls and 208 cases. Both the qualitative and quantitative components were hospital-based. Six FGDs were conducted among the control group in six of the selected hospitals and involved a total of forty-six adolescents. Eleven In-depth Interviews (IDI) were also held with every eligible adolescent who had experienced RRP (case) in six of the twelve health facilities selected for the research. STATA 15 MP (StataCorp, College Station, TX, USA) was used to analyze the quantitative aspect of the work. Univariate, bivariate and multivariate logistic regression analyses were conducted with p-value of <0.05 considered as significant. Composite score analysis was used in estimating the level of depression among the participants using Beck’s Depression Inventory scale. The qualitative data were audio recorded, translated into English and transcribed verbatim. Thematic content analysis was adopted for the analysis. Data triangulation was done to support the quantitative data using the qualitative data. RESULTS: There were two outcome variables in the study. The first one was the risk factors for RRP and the second was the effect of RRP on depression. Risk factors for RRP: The median ages at menarche between cases and controls were 12 and 13 years respectively and it was observed that most of the girls who experienced menarche at age 12 years and below were involved in early sexual activity (age at first sexual intercourse) than those who did not. It was also revealed in the study that the number of times a pregnant adolescent visits the hospital for ANC had some form of influence on the risk of RRP. The peers of the adolescents were the main source of information on issues of sex among the cases as compared with the control group. Transactional sex was more common among the cases than the controls. In a univariate analysis variables that showed significance as risk factors for RRP were planning of last pregnancy, history of miscarriage, married or living with partner, parental care, and at least 4 ANC visits. All these variables were significantly associated with odds of RRP. There was an evidence that the odds of RRP for the adolescents who have ever had a miscarriage was about eight times more than that among those who have never had a miscarriage (aOR=7.92; 95%CL: 3.18-19.71; p<0.0001). Effect of RRP on depression: The risk of being depressed among cases were 19% higher than the control group (crude RR=1.19; 95%Cl=0.99 to 1.43; p=0.070). After adjusting for the confounding variables, this increased significantly to 36% higher risk of being depressed (adjusted RR=1.36; 95%Cl=1.11 to 1.67; p=0.003) suggesting an evidence of association between RRP and depression. CONCLUSION: This research has identified the main risk factors of RRP to be, age at menarche, marital status, parental care and support, number of times of ANC visits, sex education and transactional sex. Again the study has investigated the extent to which having subsequent birth in less than 24 months (Rapid Repeat Pregnancy) could adversely affect psychological state of an adolescent mother. The results from this study could provide an insight into designing targeted interventions by policy makers and other stakeholders. Key words: Rapid Repeat Pregnancy, depression, unmatched case-control, mixed method, Antenatal visits transactional sex, menarche, cases, controls.Item Availability and Utilization of Health Care Services and the Health-Related Quality of Life of Older Adults in Greater Accra(University Of Ghana, 2018-07) Eliason, C.Background Although ageing is a desired phenomenon, it is associated with health-related challenges which affect the quality of life of older adults. These increase the demand for health care services as a growing number of older people are living with chronic diseases and disabilities. This study assessed the availability and utilization of health care services and the health-related quality of life of older adults living in Greater Accra region in Ghana. Methods It was a cross-sectional study using quantitative and qualitative approaches. The survey involved a total of 500 older adults aged 60 years and above, residing within the catchment areas of six selected health facilities in Greater Accra and assessed the factors influencing utilization, health-seeking behaviour, and health-related quality of life. The qualitative aspect explored the availability of health care services for older persons through key informant interviews with eleven curative and preventive health professionals working in the s ix selected health facilities. Thematic content analysis was employed in the qualitative data analysis. The survey utilized an integrated questionnaire that included health care utilization, health-seeking, and SF-36 Health survey for health-related quality of life among community-dwelling older adults. Descriptive, bivariate and multivariate logistic regression analyses were employed to examine the associations between population characteristics, use of health care services, health-seeking behaviour and health-related quality of life. Results Four major themes emerged from the key informant interviews that included; accessibility of services, availability of special services for older persons, affordability of health services and knowledge of policy for care of older persons. Dedicated services for older adults did not exist. However, some general curative and preventive services were available in the existing formal health system. Also, knowledge of the existence of a policy framework for older persons was inadequate among health workers. Utilization of healthcare was good (65%) among older adults. Determinants of utilization were age, residential status, source of income, employment, benefit from government, health status rating and diagnosed with chronic disease. Majority of the respondents (89%) intended to seek treatment from the hospital and did so when they fell sick. Employment status of the older person influenced their health-seeking behaviour. The overall health-related quality of life was good (mean score 57.5) despite the low physical health component score (43.8). The predictors of overall health-related quality of life were marital status, a rating of current health status, diagnosed with chronic disease and utilization of health care service. Conclusion Dedicated health care services for older adults were not available in the formal health system. Utilization of health care services was good. Majority of older adults sought health care from hospitals when they fell ill. Overall health-related quality of life was good, but the physical health functioning was limited. Population characteristics and utilization of health care services were significantly associated with health-related quality of life but health seeking behaviour was not. This study recommends that a dedicated service for the older adults need to be instituted. This may provide the basis for health management of older persons and will also help the central and local government to devise appropriate health intervention strategies to improve and promote the health-related quality of life of older persons. Key words: Older adults, health care service utilization, health seeking behaviour and health related quality of lifeItem Contraceptive Discontinuation and Switching among Women in the Shai-Osudoku and Ningo Prampram Districts, Ghana(University Of Ghana, 2018-07) Modey, E.J.INTRODUCTION: The intended and continued use of contraceptives is critical for attaining individual reproductive health goals and the prevention of unintended births that may be subject to induced abortions. Women who eventually overcome barriers and adopt a contraceptive method, encounter challenges that result in discontinuation, switching, or method failure. The occurrence of discontinuation for reasons other than the desire to conceive or switching to less effective methods, places women at an increased risk of unintended pregnancies. Identifying the period within which any form of discontinuation or switching is likely to occur and the reasons influencing these, will facilitate the identification of opportunities for providing a more accurate guide to users and encourage the delivery of context–appropriate support to users of family planning services. OBJECTIVE: This study sought to identify the occurrence of contraceptive discontinuation and switching among women in the Shai-Osudoku and Ningo Prampram districts, Ghana. METHODS: Individual in-depth interviews with 20 women reporting for reproductive and child health care services at the district Hospital were undertaken. This was complimented by a retrospective survey of 1,114 women using a structured questionnaire that incorporated the contraceptive calendar to collect reproductive histories. Cox regression and life table analysis was used to estimate discontinuation or switching. RESULTS: All method discontinuation for any reason at 12, 24 and 36 months after starting use were 4%, 18% and 38% respectively. This study identifies increasing age, number of children, use of contraceptives between births, after childbearing and receiving counselling on methods were associated with the reduced risk of contraceptive discontinuation at all times of follow up. A change in marital status and was associated with increased contraceptive discontinuation. At 12 months of use 10% of women discontinued because they are afraid of side effects of contraceptives, this increases to 37% at 24 months of use. Women who expressed fear of side effects of contraceptives had a 60% increase in the hazard of discontinuation at all times of follow up [HR=1.60 95% CI (1.17, 2.20)] whilst women who experienced side effects had a 50% increase in the hazard of discontinuation [HR=1.34; 95% CI (1.04, 1.75)] compared to women who discontinued for any other reason implying dissatisfaction with the method. A reduced need for contraceptives was associated with a 57% increase in the hazard of discontinuation at all times of follow up [HR=1.57; 95% CI (1.22, 2.01)]. Discontinuation of the pill was significantly increased compared to users of the male condom [HR=2.35, 95% CI (1.40, 3.97)] and compared to all other methods [HR=1.68; 95% CI (1.26, 2.25)]. Approximately 39% of switching occurred within the next month of use. Increasing number of children and counselling on methods were associated with a reduction in the hazard of discontinuation. The choice of switching to modern method was associated with an increased hazard at all times of follow up and the male condom was the preferred method for 20% of all switchers. Overall, 3.4% of pregnancies were identified as unintended, with the emergency contraceptive identified as the method with the most failures recorded. CONCLUSION: A reduced need for contraceptives, fear of side effects and the experience of side effects carry an increased risk of discontinuation compared to all other reasons. The strength of the influence that fears of side effects play in method selection, discontinuation and choice of method switched to where switching occurs, is a critical but amenable element if allocated the necessary attention.Item Coping with Assisted Reproductive Technology: Evidence from Clients Seeking Infertility Interventions in Selected Private Health Facilities in Ghana(University Of Ghana, 2018-10) Kyei, J.M.BACKGROUND: Infertility remains a challenge for some couples globally. Recent evidence shows that one in every six couples will face fertility problem in their reproductive age. For the past four decades, Assisted Reproductive Technology (ART) has been an effective intervention for infertility. The complexities associated with the ART presents many challenges to couples including psychological, social, and emotional difficulties. These challenges underscore the relevance of coping particularly during the process of the ART. Objectives: This study therefore sought to understand the challenges associated with ART and the various coping strategies infertile couples adopt when seeking ART. Methods: The study employed convergent parallel mixed method design. Exploratory phenomenological approach and cross-sectional survey were used for the qualitative and the quantitative studies respectively. Overall, 12 women and 6 men participated in the qualitative study, whereas 211 women participated in the quantitative study. The qualitative study employed purposive sampling technique and the quantitative used convenience sampling technique to recruit the respondents. The qualitative data was collected using in-depth interviews and the Ways of Coping questionnaire was used to collect the quantitative data. Analysis of the quantitative data was done using content analysis technique whereas the quantitative data was analysed using the Stata version 14.0. Descriptive statistics such as the mean, frequencies were determined from the quantitative data. Inferential statistics such as Chi-square test of independence, Fishers exact test, one-way analysis of variance and Kruskal Wallis were used to determine association between each of the predictors of coping and levels of coping strategy. Results: The study revealed couples with infertility problems highly value biological children due to social stigmatization about childlessness. Some respondents indicated that they have suffered various forms of psychological, emotional, and social afflictions because of their inability to have their own children. Respondents utilised ART the best alternative solution to infertility problem. Factors such as advanced age of the woman, pressure from families, particularly mothers-in-law, and friends influenced respondents’ uptake of ART. Furthermore, various ART uptake challenges, identified included anxiety about treatment outcome, high cost of ART, and long distance to ART centres. The study respondents used different coping strategies to cope with ART. These included confrontational, distance, self-control, social support, acceptance responsibility, escape-avoidance, problem solving and positive reappraisal coping strategy. The most highly used coping strategy was positive-reappraisal (n = 104, 49.3%). Fertility centre and cause of infertility were the two covariates that were significantly related to overall coping strategy. None of the covariates were associated with the positive reappraisal coping strategy. Conclusions: Having children in marriage in the Ghanaian society is very crucial. Even though ART offers a better solution to infertility, it has its own associated challenges necessitating the adoption of various forms of coping strategies. Given the importance couples attach to biological children, evidence of infertility prevalence in Ghana, Government should consider integrating ART services into the existing obstetric and gynecological facilities to serve as an alternate solution to the challenges of infertility in Ghana. Again, the reproductive health unit of the Ghana Health Service should sensitise the general public about the availability of ART, its effectiveness as well as the associated benefits. This will reduce the negative consequences of childlessness in the Ghanaian society. Given the emotional and psychological challenges reported by the clients in this study, it is recommended that counseling units should be established in these centres to offer services to clients at every stage of the treatment.Item Negative Early Reproductive Health Decisions and Associated Outcomes Among Women in the Northern Region of Ghana(University of Ghana, 2019-03) Iddrisu, M.R.Background: A growing body of demographic and sociological literature indicates that early life decisions and choices individuals make have important health consequences in later life Within reproductive health in particular, a number of studies suggest that early reproductive health decisions that women make have an impact on their reproductive health outcomes in later life. Despite this growing evidence, little understanding exists in Ghana about the relationship between negative early reproductive health decisions of women and later life reproductive health outcomes. Based on a life course perspective, this study aimed to examine the early reproductive health decisions of women and their associated reproductive health outcomes in the northern region of Ghana. Methods: A concurrent mixed methods retrospective study design was conducted to elicit information from married women within the ages of 15-49 years as well as other key informants. Systematic sampling was used to sample a total of 390 married women to take part in the survey. A combination of purposive and snowball sampling was used to select 40 key informants and a total of 130 women between ages 15- 49 with a minimum marriage experience of five years to take part in qualitative focus group discussions, in-depth interviews and key informant interviews. Quantitative data were collected through a face-face interview using structured questionnaires. Qualitative data were collected through focus group discussions, in-depth interviews and key informant interviews using unstructured topic/discussion guides. Descriptive statistical methods were used to describe important characteristics of survey respondents. Bivariate and multivariate logistic regression analyses were performed to examine association between early reproductive health decisions and reproductive health outcomes in later life. Confidence level and statistical significance were set at 95% and a p-value<0.05 respectively. Stata 13 version software was used in the analysis of the quantitative data. Qualitative interviews were audio-recorded, transcribed verbatim and analysed thematically with Nvivo 10 software. Results: Prevalence of early sex (first intercourse before age 16) was 58%, early marriage (union contracted before the age 18) was 30.0% and 80% of respondents did not consent to their marriage partner. About 42% of women have engaged in spousal communication on contraceptives. Also 24% experienced gender-based violence, 25% respondents' ever experienced unintended pregnancy and 44% experienced high fertility. The results from the qualitative study showed that persons who influence negative early Reproductive Health (RI-l) decisions of early sex, early marriage and consent of marriage partner were future partner, fathers of respondents and arranged marriages. Women who married before age 18 (early marriage) were also 3.27 times more likely to experience poor spousal communication relative to those who married between the age bracket of 26 - 36. Also women who had early sex and married early were significantly more likely to experience Gender Based Violence (GBV). The study further established a significant association between respondents experiencing early sex and GBV (p= 0.001). The odds of experiencing GBV were 2.65 times higher among women who first had sex before age 16 years (early sex) compared to those who first had sex between the ages of 16-25. Also of the respondents who had experienced unintended pregnancy, 72.5% (n=71) engaged in early sex (first intercourse before age 16). The odds of experiencing unintended pregnancy was 3.10 times higher among women who had sex before age 16 (early sex) compared to those who had sex between the ages of 16 to 25. Again, 39.8% (n=39) of the respondents who had unintended pregnancy married early. Also 81.6% (n=80) of the respondents who experienced unintended pregnancy did not consent to their marriage partner. Conclusion: The study found evidence linking negative early RH decisions of women to RH outcomes in the adult lives, suggesting that early RH choices affect later life reproductive health outcomes of respondents. These findings suggest that understanding women's current RH outcomes in the northern region requires looking closely at early life decisions which are likely to affect women later in life. Interventions in this direction can considerably improve women's health in the Northern region.Item Quality of Maternal Healthcare in Four Districts in Northern Region, Ghana(University of Ghana, 2019-07) Mumuni, V.S.Background: The quality of maternal healthcare women receive during pregnancy and delivery has attracted global attention. However, tools and empirical studies on quality of maternal healthcare women receive are lacking in many low-income settings including Ghana. Available literature shows that many of the current assessment tools are provider driven, focusing mainly on clinical care aspect of quality without considering clients' perspectives. This study aimed to fill these knowledge gaps by developing and validating an assessment tool and using same tool to assess the quality of maternal healthcare in selected districts in Northern Region of Ghana. Methods: An exploratory sequential mixed methods study design was used. This design was operationalised in three phases. The first phase was a qualitative exploration of clients' and providers' perspectives on quality of maternal healthcare. It comprised 6 focus group discussion sessions with 46 postnatal women and 39 in-depth interviews with postnatal women and 7 healthcare workers. The second phase of the design built on the first. This involved the development and validation of a quality of care assessment tool. Fifty-five (55) maternal and child health experts were purposively selected to assess quality of care domains that was proposed. The aim was to determine item's clarity and relevance on a 5-point Likert scale. The final phase involved administering the maternal healthcare quality assessment tool to a total of 520 randomly sampled postnatal women in a survey in four districts in the northern region (Tamale metropolis, Savelugu-Nanton municipality, Kumbungu and Sagnerigu districts) to assess quality of maternal healthcare they received during their most recent pregnancy. Thematic content analysis techniques were used to analyse qualitative data. Content Validity index (CVI), polychoric correlation co-efficient, and Item Response Theory (lRT) model were used, to assess suitability, correlation between items in each construct and reliability of the tool. Descriptive statistical analysis was done to describe important demographic and maternal health characteristics of survey respondents. To assess quality of maternal healthcare women received, mean quality of care scores were obtained for each domain by adding the mean scores for individual items and dividing the results by the number of items in each domain. Based on this mean score for each domain, the quality of care under each domain was then recategorized into three scales, where a mean score of 1.0 - 2.0 meant low quality; mean score of 2.1- 3.9 meant moderate quality; and mean score of 4-5 meant high quality. Percentage distribution tables were then constructed to show the proportion of respondents who rated the quality of care they received as either low, moderate or high. Findings: Results from the qualitative interviews identified a total of 13 domains of care and 57 indicators of maternal healthcare quality. These domains included proximity of health facilities to clients, availability of infrastructure and other amenities, availability of logistics including equipment and medicines and good environmental sanitation, quality of the human resource/workforce. non-discriminatory provision of maternal healthcare services, interpersonal relationship, privacy of clients, pain management, Safety, outcome of pregnancy and client's satisfaction with the care processes and outcomes. Results from the experts' evaluation of the appropriateness and validity of the 57- indicators identified from the qualitative research showed that all the items of the construct were rated above a content validity index (CVI) of 0.6, where 0.6 was the benchmark below which items would be rated as irrelevant/inappropriate. However, following modification and pretesting of the tool and further reliability testing of the items in the tool using item discrimination indices, only 47 indicators had acceptable item discrimination indices. These were, therefore, included in the final tool. Findings from the survey showed that overall, 72% of the respondents rated the quality of maternal healthcare they received as high, with 27% and 0.6% rating the quality of care as moderate and low respectively. The highest rated domain was the outcome domain with a mean score 4.26 ± 0.57. The proportion of women who rated the outcome domain as high was 91.15% while 8.08% and 0.77% of them rated it as moderate and low respectively. The least rated' domain was pain management, which had an average rating score of 3.14 ± 1.18, with 277(53.27%) of respondents rating it as high, 179(34.42%) rating it as moderate and 64(12.31%) rating as low. Conclusion: For any meaningful quality of maternal healthcare assessment to occur, there is need for including both women's and provider's perspectives. Although majority of women rated the overall quality of care, they received to be high, there is space for further improvement. There is the need for more attention to be paid to aspects of maternity care that were poorly rated by clients. In this regard, good inter-personal relationships with clients. better resourcing of health facilities and sustained collaboration between clients and healthcare providers is needed for enhancing the status of maternal healthcare in the region.Item Socio-Cultural Practices Influencing Intrapartum and Postpartum Continuum of Care In the Asante Akim North District Ashanti Region(University of Ghana, 2019-07) Ansong, J.Background: The growing recognition of the critical importance of providing care to mothers and new-borns and the substantial gaps in coverage that exists have prompted a paradigm shift in responding to maternal and new-born health issues. Invariably, the health care that a mother receives during pregnancy, at the time of delivery, and soon after delivery is important for the survival and well-being of both the mother and her child. However, evidence suggests that maternal and neonatal deaths are accentuated by socio-cultural practices along the intrapartum and postpartum continuum of care and several studies have documented this across the globe. However, in Ghana, studies on the role socio-cultural practices play along intrapartum and postpartum continuum of care remains unexplored. This study, therefore, seeks to identify the gaps in the knowledge and practices along the intrapartum and postpartum continuum of care in the Asante Akim North District of Ashanti Region of Ghana. Methods: This was a descriptive cross-sectional study which employed mixed sequential qualitative and quantitative strategies. An initial explorative study using focus group discussions and in-depth interviews was done to explore community leaders. health managers and mothers' perceptions and experiences in relation to the influence of socio-cultural practices along the intrapartum and post postpartum continuum of care. NVivo II was used to analyze the qualitative data and the themes and sub-theme converted into a survey questionnaire. A multistage sampling technique was used to sample 439 mothers with infants (0-6 months) from four subdistricts, based on proportion to population. Quantitative data was analyzed using STATA 14. Multivariable logistic regression to determine associations between independent and dependent variables was done. Results: The study found that 65.1 % of women had adequate ANC 4+, 49. JO/o had skilled delivery, and 65.4% had received postnatal care at six weeks with only 28.5% having achieved complete continuum of care. Women who practiced confinement were 2.42 times (95% C\=0.4450-0.7789) more likely to discontinue care at ANC, 1.98 times (95%CI=O. I 891.0.4000) the relative risk of discontinuing at postnatal than those who did not practice confinement. Women who believed in bewitchment during pregnancy and postnatal period had relative risk of 2.22 (95% CI=0.3634-0.9234) discontinuing at ANC, 1.67 (95% CI=0.4712-0.9178) at delivery and 2.89 (95% CI=0.4381-0.8172) during postnatal. Again, women who did not receive home visits by health care workers during pregnancy had higher relative risk of discontinuing at ANC (RR-1.89, 95% Cl=O.2190-0.9182), delivery (RR-2.71, 95% CI=0.8791) and PNC (RR=1.78, 95% C\=0.6981-0.8132). Receiving education on ANC also reduced a woman' s relative risk of interruptions along the continuum. Out of 439 participants, only 208 (47.4%) were advised to deliver in the health facilities. Women who were not advised to have skilled delivery had higher relative risk of discontinuing at delivery (RR=2.91, 95% CI=0.4001-0.7211) and PNC (RR=2.88, 95% CI=0.4412· 0.7219). Women who also reported having experienced bad attitudes from health workers were more likely to discontinue at ANC, delivery and PNC. Local practices such as use of enema and use of squatting position were reasons attributed to accessing unskilled delivery. With respect to maternal illness, 241 (55.2%) and 196 (44.8%) sought health care from biomedical and non-biomedical facilities respectively. After delivery, 88 (20.0%) sought health services from traditional healers, a factor affecting neonatal health. The study further found that 281 (65.1%) neonates experienced ill health during the neonatal period. Difficulty in breathing, 98 (34.3) and fever, 78 (27.3%) were the two most reported condition during the neonatal period. Of the 286 who fell sick during neonatal period, 201 (70.3%) sought health care whilst 85 (29.7%) did not seek health care. Among those who sought health care, 125 (62.2%) used biomedical health facilities. Conclusion: The study concludes that socio-cultural practices are common in the study area and transcends the perinatal period. These socio-cultural practices are viewed as indispensable and closely related to people's worldview that illnesses during pregnancy, childbirth, neonatal and postnatal period have social and supernatural causes. This belief system favoured accessing health care from traditional healers. The good interpersonal relationship of TBAs, local beliefs and poor services at biomedical facilities pushed expectant mothers towards traditional care. Both neonatal and postnatal illnesses were believed to have both biomedical and social causes but with social causes given more prominence. Hence, health seeking behaviour was directed toward non-orthodox service outlets; thus affecting the continuum of care.Item Community-Based Intervention to Prevent Domestic Violence against Women in the Reproductive Age in Northwestern Ethiopia: A Quasi-Experimental Implementation Research(University of Ghana, 2019-07) Demisie, A.S.Background: Violence against women is a devastating public health challenge and a pervasive human rights abuse. Worldwide, a third of women experience domestic violence from either intimate or non-intimate partner in their lifetime. In sub-Saharan Africa region, the prevalence of domestic violence against women is similar with the global picture (36.6%). In Ethiopia, domestic violence against women is a common phenomenon and forms part of women’s life experiences ranging from 19% to 78%. However, there is paucity of translation of existing evidence into community-based intervention, and piloting its implementation applicability and effectiveness in preventing domestic violence against women in Ethiopia. Objective: Assessed the implementation and outcome of a community-based intervention on the prevention of domestic violence against women and its associated factors in Awi Zone, Northwestern Ethiopia. Methods: A community-based quasi-experimental study was conducted using mixed methods to assess domestic violence against women in the Northwestern Ethiopia. Complex probability sampling design and purposive methods were used to recruit study participants for quantitative and qualitative study, respectively. Study participants were assigned into three groups; Intervention, Active comparator, and Control and given the intervention packages. The women in the intervention group received all the intervention packages. These consisted of stakeholder advocacy workshop, community mobilization, training of community agents, house-to-house women’s awareness-creation and participating partners. In the active comparator group, only partners’ participating component was not implemented. The control group were sustained on standard services. A sequential explanatory data collection method was applied for both pre and post intervention surveys. Gathered data were entered into EpiData software and exported into SPSS version 23.0 for analysis. Descriptive, Generalized Linear Models and Difference in Differences (DID) statistical analysis methods were carried out. Statistical associations were reported using adjusted prevalence ratio at 95% confidence interval (CI) and p-value less than 0.05. The qualitative data were transcribed, coded, and thematically analyzed using Nvivo 11. The study protocol was registered on trial registry platform (ClinicalTrials.gov: NCT03265626). Results: The level of domestic violence against women reduced from pre-intervention 48.3% to 40.1% at post-intervention survey. Women’s receptive attitudes towards justified wife-beating reduced from 69.9% to 59.0%. Likewise, women’s receptive attitudes towards inequitable gender-norms between wives and partners declined from 67.6% to 55.9%. In the DID analysis, women’s experience of sexual violence declined by 10% among women in the active comparator group than the control group (DID, -0.10; 95% CI: -0.19, -0.02). Women’s receptive attitude towards justified wife-beating reduced by 17% in the active comparator group compared to the control group (DID, -0.17; 95% CI: -0.26, -0.08). Likewise, women’s receptive attitude towards inequitable gender-norms reduced by 17% in the intervention as compared with the control group (DID, -0.17, 95% CI: -0.26, -0.08). Furthermore, budget constraints, lack of commitment, having community-traditional gender-norms, poor planning, lack of integration and inter-sectoral collaboration were barriers to existing policy implementation to prevent domestic violence against women. The existing community health extension program, women development ‘army’ group, existing policy frameworks, government’s political willingness, presence of school-based gender clubs and development partners were some of the enabling conditions for ensuring the sustainable implementation of domestic violence prevention programs in the study area. Conclusions: The community-based piloted intervention was effective in preventing domestic violence, receptive attitudes towards justified wife-beating and inequity-norms. However, the prevalence of the different forms of domestic VAW were still high. Both women’s receptive attitude towards justified wife-beating and inequitable gender-norms were interlinked factors associated with persistently high domestic violence against women. The community’s receptive attitude is also exhibited by local politicians and or implementers. Community-based intervention was found to be effective, feasible and applicable in reducing domestic violence and its receptive attitudes. The implementation of existing policies to prevent domestic violence against women was poor due to lack of inter-sectoral collaboration, poor integration and stakeholders having competing priorities among others. It is suggested that programs focus on intersectoral collaboration and service integration with existing programs to sustain and synergize domestic violence prevention intervention.Item Predictors of Intrapartum Stillbirths in Singletons in Six Public Hospitals in the Greater Accra Region, Ghana(University of Ghana, 2019-07) Vanotoo, L.A.Introduction . Globally. 2.6 million stillbirths are recorded annually: 50% occur during labour (intrapartum). Ghana records 11,000 stillbirths annually and 40% occur during. labour. The Greater Accra Region records 2000 stillbirths annually: 40 % of them occur intrapartum. An understanding of the contributory factors will facilitate the development of preventive strategies to reduce the huge numbers of intrapartum stillbirths. Objectives The objectives of this study were to identify contributors to intrapartum stillbirths; explore perceptions about stillbirth from women with experience of intrapartum stillbirth, document views of health professionals about causes and prevention of intrapartum stillbirths and develop a model to predict intrapartum stillbirths. Method This was a retrospective 2: I unmatched case-control study with a qualitative component. The study sample was all deliveries between 1st January to 31st December 2016 in six public hospitals in the Greater Accra Region. Cases were selected through census while controls were selected from the live births using systematic random sampling. Relevant information was retrieved from clinical records for both cases and controls. Thirteen (10%) women from the cases and 14 health workers were purposively selected for in-depth interviews. Bivariate and multi variable data analyses were used to determine association between the variables and intrapartum stillbirth. Qualitative data were analysed by themes using NVIVO II. The Area Under the Receiver Operating Characteristics Curve (AUROq and the Brier Score (BS) were used to identify factors to include in the model to predict intrapartum stillbirths. Approval for the study was obtained from the Ghana Health Service Ethics Review Committee. Results During the study period. there were 36,168 deliveries with 918 stillbirths; 362 (39%) occurred intrapartum. Through the census, 125 cases were identified, in addition, 250 controls and 27 participants were included in the study. Mean age of cases and controls were 28.8= 5.54 and 28.9 ± 6.05 years respectively. Mean gestational age was 36.5 ± 3.95 weeks for cases and 38.8 ± 2.69 weeks for controls; median birth weight was 2. 7kg.± 0.92 for cases and 3.1kg ± 0.65 for controls. The following maternal factors were associated with intrapartum stillbirths: pregnancy-induced hypertension (PIH) (aOR 3.70); antepartum haemorrhage (APH) (aOR, 3.28) and premature rupture of membranes (PROM) (aOR 3.36). The major fetal contributory factor was low gestational age (aOR. 0.86). Service delivery factors included lack of trained health staff, inadequate number of beds, theatre space. Non use of partograph to monitor women in labour and non-auditing of perinatal deaths. Fetal autopsy was not performed on stillbirths. The best model to predict intrapartum stillbirth was the model with combination of maternal (PHI. APH and PROM); fetal (low gestational age) and service delivery (mode of delivery and health provider who conducted the delivery) factors. Conclusions and recommendations Improved management of PIH, APH, PROM and preterm delivery will reduce intrapartum stillbirth. Hospitals should improve on monitoring of women during labour. Auditing of intrapartum stillbirths should be mandatory for all hospitals and Ghana Health Service (GHS) should include fetal autopsy in stillbirth auditing to identify other causes of fetal deaths. The best model to predict intrapartum stillbirth is a combination of maternal, fetal and health service delivery factors. Thus, interventions to reduce intrapartum stillbirth must combine maternal, fetal and service delivery factors to make them effective.Item Determinants of Adherence and Treatment Outcomes Among Adolescents Living with HIV in Cameroon(University of Ghana, 2019-07) Bongfen, M.C.Background: Despite over three decades of HIV, its prevalence especially among adolescents remains a public health concern. In 2015, there were more than two million adolescents living with HIV, with a higher proportion coming from sub-Sahara Africa. In Cameroon, there are over 40,000 adolescents living with HIV and there are still concerns about the provision of care to them as adolescents are trapped between paediatric and adult services which are unable to address their specific needs. However, there are limited studies in Cameroon that have examined adherence to antiretroviral treatment and associated factors as well as treatment outcomes among adolescents. It is therefore essential to clearly understand the determinants of adherence of these adolescents and their treatment outcomes. Objectives: The main objective of the study was to assess the determinants of adherence to Anti-Retroviral Therapy and treatment outcomes among adolescents living with HIV in Cameroon. Methods: The study was an analytical cross-sectional Study with a record review component. A total of 460 respondents were recruited from nine health facilities. A systematic random sampling procedure was used to select the required participants. Pretested questionnaires were administered to participants to collect data. The main outcome of interest (adherence) was measured in two ways: self-report adherence, and medication possession ratio (MPR). Three treatment outcome measures that were assessed included viral load suppression, retention in treatment, and CD4 counts. Finally, health facility readiness towards care for adolescents on ARV was assessed using the John Snow Inc. (JSI) tool. Descriptive (frequencies and proportions) and inferential (chi square and multivariate logistic regression) statistical analyses methods were used to analyse the data. Statistical significance was set at p<0.05 at a 95% confidence level. Results: A total of 455 questionnaires were retained and this gave a response rate of 99%. The average age of the adolescents was 14.8years (SD= ±2.9years). There were more females (55%) than males (45%) in the study. A larger proportion of the respondents were on first line treatment (77%) and had been on treatment for an average of five years. Self report adherence was 83% while MPR was 73%. The difference in adherence between self report and the Medication Possession ratio was not statistically significant (p=0.97). Regarding the determinants of adherence, 12 out of 30 independent variables examined showed significant statistical association with adherence at the bivariate level. In multivariable logistic regression analyses however, only two variables significantly predicted adherence, namely experiencing side effects (AOR= 2.63; 95%CI=1.14, 6.09; p = 0.02) and internalized stigma (AOR=2.51; 95%CI =1.04, 6.04; P = 0.04). The major challenges to adherence were stigma (59%) and forgetfulness to take medications (59%) while sending reminder messages and having friendlier health providers were the main suggestions to help improve on adherence. In terms of treatment outcomes, 70% of the respondents had their viral load suppressed. The retention rates were observed to decrease over time: 88%, 72% and 58% at 6months, 12 months and 24 months respectively. All the selected facilities were shown to be ready to receive adolescents into treatment as 7 out of the 9 facilities were in stage 5 of the facility readiness assessment. Conclusion: The determinants of adherence among adolescents are more psychological than the physical characteristics that differentiate them. There is therefore a need for more individual-targeted counselling for adolescents and their guardians to improve adherence levels among adolescents on antiretroviral treatment.Item Assessment Of Quality Of Healthcare Among The Elderly Patients Utilising The Korle-Bu Teaching Hospital, Accra(2019-12) Wuaku, D.A.Background: The elderly tend to have a disproportionately high need for utilisation of healthcare services because they exhibit multiple disorders, have limited regenerative abilities, and are prone to diseases, syndromes, and sicknesses. These elderly persons are relatively regular consumers of the Out Patient Department’s care. The seeming lack of provision of suitable and quality healthcare services to the elderly is emerging as one of the main impediments of this era. The fundamental requirement to increase utilisation for the elderly persons is to improve the quality of healthcare services delivered in hospitals. Objective: The study sought to assess the quality of healthcare services among the elderly patients utilising the Korle-Bu Teaching Hospital, Accra. Methods: The study was a descriptive cross-sectional survey using a sequential explanatory mixed methods approach. In the quantitative study, questionnaires were used to elicit information from three hundred and sixty-one (361) elderly persons. Purposive sampling was used to select elderly persons from the seven Out-Patient Departments in the Korle-Bu Teaching Hospital in Accra. Simple random sampling [lottery method] was used to select the elderly persons in the inclusion criteria. The quantitative data was analysed by the use of chi-square test to determine the relationship between the socio-demographic characteristics of the elderly and the variables measuring utilisation of healthcare services (cost, accessibility, health personnel attitude, physical support, information and waiting time). In addition, Ordinal Logistic Regression was used to determine the relationship between the predisposing, enabling and need factors of the elderly and each of the variables measuring utilisation of healthcare services. Furthermore, one-way analysis of variance and Generalised Linear Model were used to examine the socio-demographic characteristics and quality of healthcare. In the qualitative study, purposive sampling method and then convenience sampling method were used to select seventy-six (76) elderly persons from the seven selected Out- Patient Departments. Qualitative study was conducted to obtain an in-depth understanding of the quality of healthcare services by the elderly patients utilising the Korle-Bu Teaching Hospital. Thematic content analysis was used to analyse the data. The interview transcripts were read to identify emerging themes and sub-themes, and were exported into Nvivo version 11 software for data organisation. Quantitative Results: The study showed that, the elderly persons who were accompanied to the health facility were 1.86 times more likely (OR=1.86, 95% CI; 1.13-3.08) to rate accessibility of healthcare services on a higher scale than the elderly persons who visited the hospital by themselves (p=0.016). The elderly who were beneficiaries of NHI were 0.42 times less likely (OR=0.42, 95% CI; 0.18-0.97) to rate accessibility of healthcare services on a higher scale compared with the elderly who were non-beneficiaries (p=0.042). The elderly persons with secondary school education and above were 0.53 times less likely (OR=0.53, 95% CI; 0.34-0.84) to rate cost on utilisation of healthcare services on a higher scale compared with the elderly persons with pre-secondary education (p=0.006). Adjusting for other factors, the elderly persons with multiple chronic conditions were 1.56 times more likely to rate cost on a higher scale compared with the elderly with one chronic condition (OR=1.56, 95% CI=1.04-2.34) (P=0.03). Furthermore, the study reported that, there was a decreasing trend in the rating of quality of healthcare services with increasing number of chronic conditions (p=0.042). The results indicated that both female and male elderly persons regarded quality of healthcare to be the same (p=0.808). Qualitative Findings: The elderly persons described the waiting time as long and stressful. They developed swollen feet and bodily pains due to the long waiting time. They clarified that the diagnostic investigation, medication and consultation fees were expensive, leading to postponement of their subsequent visits and deterioration of their health. Additionally, the elderly persons specified that they woke up very early to report timely at the Out-Patient Departments by means of ‘drop in’ taxi that was very costly. Furthermore, at the Out-Patient Department, they faced cumbersome procedures before seeing the doctors. With respect to the quality of healthcare provided at the hospital, feedback from the health personnel was reported harshly, and they provided negligible physical assistance. The elderly described the seats at the waiting rooms as being very low and uncomfortable. Nevertheless, the elderly persons described the health personnel as skillful and knowledgeable. Unexpectedly, the elderly were satisfied with the healthcare services at the Korle-Bu Teaching Hospital. For the elderly participants, satisfaction meant improvement in their health. Conclusion: Cost was a determining factor in utilising healthcare by the elderly patients. The health personnel were described as being skillful and knowledgeable in providing healthcare. The improvements in the general health of the elderly made them satisfied with healthcare services. Recommendations: The study recommends that policy makers should include elderly persons from age 60 years to 69 years in the National Health Insurance exemption policy to enable the majority of them to utilise the healthcare services. Additionally, there is the need to review visits to the healthcare units to schedule time appointments to reduce the long and stressful waiting time. .Item Addressing Malnutrition: The Importance of Political Economy Analysis of Power(International Journal of Health Policy and Management, 2020) Walls, H.; Laar, A.; Nisbett, N.; et.alBackground: The exercise of power is central to understanding global health and its policy and governance processes, including how food systems operate and shape population nutrition. However, the issue of power in food systems has been little explored empirically or theoretically to date. In this article, we review previous work on understanding power in addressing malnutrition as part of food systems that could be used in taking this issue further in future food systems research. In particular, we examine why acknowledging power is vital in addressing food systems for better nutritional outcomes, approaches to assessing power in empirical research, and ways of addressing issues of power as they relate to food systems. Methods: We undertook a narrative review and synthesis. This involved identifying relevant articles from searches of PubMed and Scopus, and examining the reference lists of included studies. We considered for inclusion literature written in English and related to countries of all income levels. Data from the included articles were summarized under several themes. Results: We highlight the importance of acknowledging power as a critical issue in food systems, present approaches that can be taken by food-systems researchers and practitioners in assessing power to understand how power works in food systems and wider society, and present material relating to addressing power and developing strategies to improve food systems for better nutrition, health, and well-being. Conclusion: A range of research approaches exist that can inform the examination of power in food systems, and support the development of strategies to improve food systems for better nutrition, health, and well-being. However, there is considerable scope for further work in this under-researched area. We hope that this review will support the necessary research to understand further power in food systems and drive the much-needed transformative change.Item Institutional Approaches to Research Integrity in Ghana(Science and Engineering Ethics, 2020) Laar, A.K.; Redman, B.K.; Ferguson, K.; Caplan, A.Research misconduct (RM) remains an important problem in health research despite decades of local, national, regional, and international efforts to eliminate it. The ultimate goal of every health research project, irrespective of setting, is to produce trustworthy findings to address local as well as global health issues. To be able to lead or participate meaningfully in international research collaborations, individual and institutional capacities for research integrity (RI) are paramount. Accordingly, this paper concerns itself not only with individuals’ research skills but also with institutional and national policies and governance. Such policies and governance provide an ethical scaffold for the production of knowledge and structure incentives. This paper’s operational definition of research therefore draws from the Institute of Medicine’s articulation of health research as an inquiry that aims to produce knowledge about the structure, processes, or effects of personal health services; and from an existing health systems framework. The paper reviews the research regulatory environment and the ethics apparatus in Ghana and describes a project jointly undertaken by Ghanaian researchers in collaboration with New York University to assess the perceived adequacy of current institutional practices, opportunities, and incentives for promoting RI.Item A Review of Leadership and Capacity Gaps in Nutrition Sensitive Agricultural Policies and Strategies for Selected Countries in Sub-Saharan Africa and Asia(Food and Nutrition Bulletin, 2020) Aryeetey, R.; Covic, N.Background: Agriculture policies and strategies designed, purposefully, to address malnutrition are considered nutrition-sensitive and are a critical component of global efforts to address malnutrition in all its forms. However, limited evidence exists on the extent and how nutrition is being integrated into agriculture sector policies, strategies, and programs. A review was conducted to address 2 questions: How nutrition-sensitive are agriculture policies, plans, and investments in selected Sub-Saharan African (SSA) and Asian countries? and Which capacity and leadership gaps limit scale up of nutrition-sensitive agriculture Policy and programs? Methods: The review of existing policies was conducted for 11 selected focus countries (9 in SSA and 2 from Asia) of the CGIAR (Consultative Group on International Agricultural Research) Collaborative Research Programme on Agriculture for Nutrition and Health led by the IFPRI (International Food Policy Research Institute). The Food and Agriculture Organization (FAO)’s 10-point key recommendation for designing nutrition-sensitive agricultural interventions was used as an analytical framework. Additionally, a rapid systematic review of published peer-reviewed and grey literature was carried out to identify capacity gaps based on the United Nations Development Program’s capacity assessment framework. Results: We found that there is nutrition sensitivity to the policies and strategies but to varying degrees. There is limited capacity for optimum implementation of these policies, programs, and strategies. For most countries, there is a capacity to articulate what needs to happen, but there are important capacity limitations to translate the given policy/program instruments into effective action. Conclusions: The gaps identified constitute important evidence to inform capacity strengthening of nutrition-sensitive actions for desired nutrition and health outcomes in Africa and Asia.