University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA DEPARTMENT OF HEALTH POLICY PLANNING AND MANAGEMENT ECONOMIC BURDEN OF DOMESTIC VIOLENCE AGAINST WOMEN IN THE LEDZOKUKU AND KROWOR DISTRICTS OF THE GREATER ACCRA REGION, GHANA. BY JOHN BAPTIST AMISSAH 10361956 THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, John Baptist Amissah, hereby declare that with the exception of references made to other works that have been duly acknowledged, that this dissertation is entirely my own work. …………………….. JOHN BAPTIST AMISSAH (INVESTIGATOR) DATE: ……………… ………………………… DR. PATRICIA AKWEONGO (SUPERVISOR) DATE: …………………… i University of Ghana http://ugspace.ug.edu.gh DEDICATION To my wife, Rachel and lovely daughter, Lady Janetta for the joy, love and strength you gave throughout pursuing this degree. To my bulwark forever, Mrs. Sarah Amissah for the gift of hardwork and resilience. To all the victims of domestic violence, may your joy be restored. ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENTS I am grateful to the Almighty God who granted me the knowledge, wisdom and strength to complete this dissertation. I wish to express my sincere gratitude to the participants of this study without whose immense cooperation this work would not have been completed. My heartfelt gratitude to Dr. Patricia Akweongo for providing exceptional support and encouragement throughout the journey of this project. I was blessed to have you as my supervisor. My deepest gratitude goes to my forever loving and caring wife, Mrs. Rachel Offeibea Amissah and my lovely daughter, Lady Janetta Nkunyim Amissah for their unrelenting and unwavering support throughout this work. My sincere thanks to Mr. Daniel Boateng who led the research assistants in collecting data for this work. I would also like to thank the staff of the Kpeshie Domestic Violence and Victim Support Unit especially, Chief Inspector Donatus Zumah for their immense help in making this project a reality. Finally, I would like to thank the new family I made in the pursuance of this Master’s degree including coursemates and staff, whose encouragement kept me going. Thank You. iii University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS LIST OF FIGURES ...................................................................................................................... vii LIST OF TABLES ....................................................................................................................... viii LIST OF ABBREVIATIONS ........................................................................................................ ix CHAPTER ONE ............................................................................................................................. 1 1.0 INTRODUCTION .................................................................................................................... 1 1.1 Background ........................................................................................................................... 1 1.2 Problem statement ................................................................................................................. 3 1.3 Justification ........................................................................................................................... 4 1.4 Conceptual Framework of the Economic Burden of Domestic Violence ............................. 4 1.5 Objectives .............................................................................................................................. 6 1.6 Research Questions ............................................................................................................... 6 CHAPTER TWO ............................................................................................................................ 7 2.0 LITERATURE REVIEW ......................................................................................................... 7 2.1 Types and scope of domestic violence .................................................................................. 7 2.2 Impact of domestic violence ................................................................................................. 7 2.3 Economic cost of domestic violence ..................................................................................... 8 2.4 Costing Studies .................................................................................................................... 10 2.4.1 Evolution of Cost-of-Illness Analysis .......................................................................... 10 2.4.2 Constituents of Economic Costs of Disease ................................................................. 11 2.4.3 Types of Cost-of-Illness Studies................................................................................... 12 2.4.4 Evaluation in Cost-of-Illness Studies ........................................................................... 13 2.4.5 Discounting and Sensitivity Analysis ........................................................................... 15 2.4.6 Applications of Cost of Illness Studies......................................................................... 15 2.4.7 Cost of Illness Studies for Domestic Violence Victims ............................................... 16 2.5 Conclusion ........................................................................................................................... 16 CHAPTER THREE ...................................................................................................................... 18 3.0 METHODOLOGY ................................................................................................................. 18 3.1 Study design ........................................................................................................................ 18 iv University of Ghana http://ugspace.ug.edu.gh 3.2 Study area ............................................................................................................................ 19 3.3 Study population ................................................................................................................. 20 3.4 Sample size calculation ....................................................................................................... 20 3.5 Sampling method................................................................................................................. 21 3.6 Study variables .................................................................................................................... 22 3.7 Data collection, techniques and tools .................................................................................. 23 3.8 Data analysis ....................................................................................................................... 24 3.8.1 Background characteristics ........................................................................................... 24 3.8.2 Estimation of direct cost ............................................................................................... 24 3.8.3 Estimation of Indirect Costs ......................................................................................... 25 3.8.4 Estimation of Intangible costs ...................................................................................... 26 3.9 Quality control..................................................................................................................... 27 3.10 Sensitivity Analysis ........................................................................................................... 27 3. 11 Ethical considerations ...................................................................................................... 28 CHAPTER FOUR ......................................................................................................................... 31 4.0 RESULTS ............................................................................................................................... 31 4.1 Background characteristics of respondents ..................................................................... 31 4.2 Total Cost of Domestic Violence .................................................................................... 33 4.3 Intangible cost.................................................................................................................. 37 4.4 Sensitivity analysis .......................................................................................................... 38 CHAPTER FIVE .......................................................................................................................... 40 5.0 DISCUSSION ......................................................................................................................... 40 5.1 Socio-demographic factors and exposure to domestic violence ......................................... 40 5.2 Direct Cost........................................................................................................................... 41 5.3 Indirect Cost ........................................................................................................................ 42 5.4 Intangible Cost .................................................................................................................... 43 CHAPTER SIX ............................................................................................................................. 45 6.0 CONCLUSION AND RECOMMENDATION ...................................................................... 45 6.1 CONCLUSION ................................................................................................................... 45 6.2 RECOMMENDATION ...................................................................................................... 45 REFERENCES ............................................................................................................................. 47 APPENDIX 1 ................................................................................................................................ 52 v University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 ................................................................................................................................ 56 APPENDIX 3 ................................................................................................................................ 58 vi University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual framework of household costs of domestic violence ................................... 5 Figure 2: Study design of the economic cost of domestic violence .............................................. 18 Figure 3: Map of LEKMA ............................................................................................................ 20 Figure 4: Cost Profile of Domestic Violence ................................................................................ 34 Figure 5: Intangible cost of Domestic Violence Victims.............................................................. 37 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1................................................. Operational Definition and Measurement of the Variables Table 2………………………………. Estimation of Indirect Cost Table 3………………………………..Composite Intangible Score Table 4...................................................Background Characteristics of Respondents Table 5................................................... Average Household Cost of Domestic Violence Table 6…………………………………Total Cost of Domestic Violence Table 7……………………………… Association of high intangible cost with background characteristics Table 8…………………………………. Sensitivity Analysis of Total Cost viii University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS BOG -Bank Of Ghana COI -Cost-of-Illness DOVVSU -Domestic Violence and Victim Support Unit DV -Domestic violence GDHS - Ghana Demographic and Health Survey GFLHS -Ghana Family Life and Health Survey HIV -Human Immunodeficiency Virus IPV -Intimate partner violence SDG - Sustainable Development Goal UN -United Nations VAW - Violence Against Women WHO - World Health Organization ix University of Ghana http://ugspace.ug.edu.gh ABSTRACT BACKGROUND: Violence against women is considered a violation of their basic human rights. WHO reports that at least one in three women have experienced some form of physical or sexual abuse at some point in their lifetime. Civil society and governments around the world have acknowledged violence against women as a major obstacle to development. It has a major impact on the health status of the woman leading to low productivity, high cost of treatments (legal, hospital and law enforcement expenses) and indirect cost to other family members. OBJECTIVE: To determine the economic burden of domestic violence against women in households in two districts in the Greater Accra Region. METHOD: A retrospective cross-sectional study was done using cost of illness approach to determine the cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region. Using a sample size of 120 the direct cost was estimated and indirect cost estimates were determined by use of the Human Capital approach. Intangible cost was estimated using a Likert scale. The overall cost was estimated by summation of the total direct cost and total indirect cost. RESULTS: This study found the total cost of domestic violence against women to be GHS 121,005.68(USD 22,745.43) with the direct cost being GHS 73,017.33(USD 13,725.06) and indirect cost of GHS 47,988.35(USD 9,020.37) representing 60% and 40% of the total cost respectively. The study also found that majority (89%) of the victims had high intangible cost and 11% reported medium or moderate levels of intangible cost x University of Ghana http://ugspace.ug.edu.gh CONCLUSION: This study provides an insight into the cost burden of domestic violence against women highlighting that both direct and indirect costs contribute significantly to the burden. Enforcing policies that prevent domestic violence against women could improve the socio- economic status of women and also reduce health care expenditures. xi University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE 1.0 INTRODUCTION 1.1 Background Domestic violence (DV), has been defined to occur when one partner attempts, at least, by physical or psychological means to dominate and control the other (Australia Office of the Status of Women Report, 2004). While the entire effect and impact of domestic violence may be difficult to ascertain, women are usually the victims, with the World Health Organisation (WHO) reporting that between 10% and 69 % of women (from 48 population-based surveys from around the world) reported being physically assaulted by an intimate male partner at some point in their lives (WHO 2003). Domestic violence however could generally apply to involve violence against children, parents, or even the elderly. It takes a number of forms, including physical, sexual violence, threats and intimidation, emotional, economic or financial deprivation, religious, and reproductive, which could range from elusive and mild forms, coercive forms to severe forms such as marital rape and violent physical exploitation such as choking and female genital mutilation or even death (Australia Office of the Status of Women Report, 2004). The role of women in all societies worldwide is crucial, and they are an important driving force in any nation’s economic growth. Gender inequality affects the voice of women especially and does not give them the opportunity to express themselves and this mars economic development (Center for Research on Women International, 2008). As a result of their role in society, violence against women is considered a violation of their basic fundamental human rights (Africa Works Report, 2017). It is quite common in both developed countries and developing countries but more so in the latter. Effects of this kind of abuse affects the health status of women both physically and mentally, which results in negative health outcomes including gynaecological disorders, adverse pregnancy 1 University of Ghana http://ugspace.ug.edu.gh outcomes, irritable bowel syndrome and most importantly, chronic pain outcomes. They tend to have more mental health issues such as depression, anxiety, suicidality, alcohol and drug abuse (Ellsberg et al, 2008). The problem of DV with its effects are not distant from Ghana and the sub-region. Many reports suggest unequal gendered social norms which are deep-seated in many cultures of African societies, thereby resulting in widespread discrimination towards women in many relationships and homes (Adu-Gyamfi,2014). There have been various international and national efforts to help curb the burden of domestic violence in Ghana, which is common because of the masculinized nature of the nation. However the economic burden of domestic violence is not fully known, and therefore remains a challenge to policy makers (Damenshie-Brown, 2013). Aside the direct cost of managing victims of DV, there is indirect cost from the psychological and mental effects, restricted livelihood options and life choices, resulting in lower human capital and lower productivity (Shuib et al., 2013). The patterns of incidence have also been reviewed in order to understand which women are mostly affected by domestic violence. In Ghana, the recent Ghana Family Life and Health Survey, showed that young women are most likely to have experienced domestic violence in the past 12months than older women ( Ghana Statistical Services, 2016). Factors such as wealth occupation, age and ethnicity were not considered to be significant predictors in domestic violence in Ghana (Africa Works Report., 2017). However other studies done in Ghana show that exposure to violence in childhood, low asset levels, educational level and unemployment correlate with higher incidence of domestic violence ( Ghana Statistical Services, 2016) . 2 University of Ghana http://ugspace.ug.edu.gh The impact of DV traverses beyond the health effects on the particular victim. A crucial effect of DV is also the economic burden it brings to the household. Many civil societies and governments around the world have acknowledged violence against women as a major obstacle to development. It has a major impact on the health status of the woman leading to low productivity, high cost of treatments (legal, hospital and law enforcement expenses) and indirect cost to other family members, including children (Fourozan et al, 2007). 1.2 Problem statement Globally, 35% of women have experienced some form of violence in their lives and this has a huge impact on their well-being and health as a whole(World Health Organisation, 2017). Similarly in Ghana, the proportion of women who suffer in the country is estimated at 28%, but this could be much more, as many victims are said to not seek formal services (Ghana Statistical Services, 2016). Several studies suggest that the economic cost of domestic violence is enormous, reporting as much as USD 3.5 billion dollars to 67 billion dollars in the United States, and 23 million pounds in the United Kingdom (Duvvury et al, 2000). It is also estimated to cost approximately 2.5million US dollars in Uganda (Garcia-Moreno & Watts, 2011), while a Ghanaian study on violence against women and girls reported an annual loss of USD 18.6 million dollars by households in the country(Asante et al., 2019) The World Health Organisation, World Bank, among other organisations have encouraged use of Costing studies to assess and implement prevention and management policies and strategies 3 University of Ghana http://ugspace.ug.edu.gh (WHO, 2003). Though DV has been costed in many places, very little has been done in Ghana. This study therefore seeks to determine the economic burden of domestic violence in Ghana. 1.3 Justification Dozens of studies have been done to determine the household cost of DV, but these are mostly in developed countries (Duvvury et al., 2000). In view of the limited data concerning the cost of DV in Ghana and the sub-region, this study may fill the gap by ascertaining the economic cost of the situation. Putting monetary value to DV may also strengthen political will and put the situation in context to other disease and condition burdens, to help in fund prioritization. This study may also give a current perspective and inform the economic framework for program evaluation regarding domestic and intimate partner violence. It may further, be a necessary tool for policy and institutional assessment. 1.4 Conceptual Framework of the Economic Burden of Domestic Violence Economic or household cost generally consists of three main components; direct, indirect and intangible cost. As illustrated in Figure 1, the conceptual framework describes the components of the economic burden of domestic violence and some factors that lead to its occurrence in households. It describes the costs associated with domestic violence and major factors associated with its occurrence. These major factors that lead to domestic violence which include unemployment, socio-economic factors and educational level have been shown to correlate with a higher incidence of domestic violence. The direct cost is made up of medical costs incurred as a result of injuries sustained and legal fees for the legal processes involved. The direct cost also 4 University of Ghana http://ugspace.ug.edu.gh includes the non-medical and non-legal costs such as transportation cost to and from the hospital and police station as well as food and consumables used within the period. In certain cases of violence, there is damage to clothing, jewelry or property, which are included in the direct cost of DV. Indirect cost on the other hand refers to productivity losses as a result of injuries sustained by victims, as well as the absenteeism from work. Intangible costs are defined by the psychological factors these victims of violence face and forms a major part of the costs associated with violence. Figure 1: Conceptual framework of household costs of domestic violence 5 University of Ghana http://ugspace.ug.edu.gh 1.5 Objectives General objective To determine the economic cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana. Specific objectives 1. To determine the direct cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana. 2. To determine the indirect cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana 3. To determine the intangible cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana 4. To assess the patterns of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana 1.6 Research Questions 1. What is the direct cost of domestic violence in the Ledzokuku and Krowor districts of Ghana? 2. What is the indirect cost of domestic violence in the Ledzokuku and Krowor districts of Ghana? 3. What is the intangible cost of domestic violence in the Ledzokuku and Krowor districts of Ghana? 4. What are the patterns of domestic violence in the Ledzokuku and Krowor districts of Ghana? 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO 2.0 LITERATURE REVIEW 2.1 Types and scope of domestic violence Historically five main factors have been identified as determinants of domestic violence; individual psychological factors, sociological factors, male aggression, poverty and the prevalence of cultures of violence ( Ghana Statistical Services, 2016) . However these factors are more generalized for developed countries in which interpersonal relationships, male aggression and psychological factors are more prominent as predictive factors for domestic violence ignoring poverty and the culture of unequal gender relations which form the core determinants in developing countries(Manyazewal, 2017). Studies carried out by Tenkorang et al,2013 showed that factors such as wealth, occupation, age and ethnicity are not significant predictors of Violence against women(VAW) and this was debunked by the Ghana Family Life and Health Survey in 2016 which showed that major determinants of VAW are age; exposure to violence in childhood, educational level, low asset levels and unemployment and to a lesser extent cultural practices such as early marriages also promotes domestic violence(Africa Works Report., 2017). 2.2 Impact of domestic violence A major cause of injury to women in developing countries is physical abuse and not only does this affect their health status it extends to their general well-being and affects them socially and economically as well (Oice et al, 2013).Violence against women has become a major public health issue in recent times and is regarded as a fundamental social issue and violation of human rights. 7 University of Ghana http://ugspace.ug.edu.gh According to the 1993 declaration by the UN, Violence against women (VAW) is defined as “any act of gender-based violence that results in, or is likely to result in, physical, sexual, or psychological harm or suffering to women, including threats of such acts, coercion, or arbitrary deprivation of liberty, whether occurring in public or in private life”. The definition covers a wide range of violence which includes social, physical, sexual, economic and psychological abuse(Ghana Statistical Services,2016) . The various forms of violence , the associated costs and consequences considered in its entirety makes violence against women a pervasive phenomenon and has increasingly become a concern for global policy(Oice et al., 2013). Generally, poor health outcomes are associated with VAW ranging from minimal injuries to chronic psychological problems, HIV and suicidality are amongst the most severe complications (Fourozan et al., 2007). Most of these women tend to seek health care at their own cost and incur a very huge burden when it comes to health care costs (Center for Research on Women International, 2008). Economically, VAW is considered to decrease productivity since all forms of violence have an impact on the ability to work, not only via physical injury, but also through mental health which affects the number of days worked (Oice et al., 2013). VAW is considered to be a developmental issue as viewed by the UN and is an obstacle to any country’s development due to its detrimental effects on the region or country’s economy(Shuib et al., 2013). 2.3 Economic cost of domestic violence Costs of violence against women are widespread throughout society. Every aspect of VAW has a cost attached to it. The costs can be grouped into four categories; direct and tangible, direct and intangible, indirect and tangible and finally indirect and intangible (City, 2008). 8 University of Ghana http://ugspace.ug.edu.gh Direct and tangible cost refers to costs associated with the provision of a range of facilities, resources and services to a woman as a result of her being subject to domestic violence (Day et al, 2005). Examples are costs such as taxi fare and health care facility costs. Direct and intangible costs have monetary value in the economy, but are measured as a loss of potential. Examples are lower earnings and profits resulting from reduced productivity. Lost personal income, for example, can be estimated by measuring lost time at work and multiplying by an appropriate wage rate(City, 2008). Direct intangible costs result directly from the violent act but have no monetary value. Examples are pain and suffering, and the emotional loss of a loved one through a violent death. Indirect intangible costs result indirectly from the violence, and have no monetary value. Examples are the negative psychological effects on children who witness the violence. The above-mentioned cost are mostly borne by victims of domestic violence and extends to include the family and further extends to involve government expenditure. There are various areas in which these cost are incurred and notable among them is health, justice, social services and business/employment costs(Laing & Bobic, 2002). There is a strong link between violence against women and health care usage such that it becomes inevitable for victims to spend in a health facility (Sheridan, 2007). A study done by WHO (2013), showed that 41 percent of women who suffered from domestic violence had sustained injuries severe and debilitating enough, and reported for medical care. A study done in Australia on the costs of domestic violence estimates health expenses by victims of domestic violence totaling AUS$314million (USD 216million) in the year 2002 to 2003. 9 University of Ghana http://ugspace.ug.edu.gh Hospital expenses and pharmaceutical expenses form about two thirds of the total expenditure in health care facilities (Laing & Bobic, 2002). In the United States, the direct costs of mental and health services related to domestic violence was estimated at USD 4.1 billion and similarly in the UK the estimates from health services incurred by victims was about 3.8 million pounds(Day et al., 2005). In developing countries such as Ghana, most victims will pay out-of-their pockets as this is the major source of health financing in the country(Akazili et al., 2017). There are also indirect costs and intangible costs which are not mostly quantified to give a clear view of the detrimental effects on the quality of life after an episode of violence. 2.4 Costing Studies 2.4.1 Evolution of Cost-of-Illness Analysis Based on the assumption that the economic costs of illness represents the benefits that are economically derived from a health care intervention should the illness be eradicated, Cost of Illness (COI) analyses has been suggested to be the earliest form of economic evaluation in the health care sector (Tarricone, 2006). Cost-of-Illness, referred to by some authors as Burden of Disease (BOD) (Jo, 2014) defines the various facets of a disease and its impact on health outcomes in individuals, communities, specific regions and countries. The first detailed description of Cost of Illness analysis is attributed to the health economist Rice (1985), with his work reviewing previous COI analysis done in 1963 and 1972 which determined the economic burden resulting from various diseases, morbidities and mortalities in the United States in 1980. It however seems to be evident that some COI analysis were in formal use well before 1960s (Tarricone, 2006). 10 University of Ghana http://ugspace.ug.edu.gh 2.4.2 Constituents of Economic Costs of Disease While the cost of disease may be borne by either the household or the institution/state as a whole, cost on COI studies are broadly categorized into direct, indirect and intangible costs. Direct Cost: Direct costs refers to the use of resources of a certain value to directly influence the provision of treatment (Anders et al,2013). This may be healthcare costs and costs not related to health. The former, refers to the health care expenditures for diagnosing and treating disease conditions, continuing care, rehabilitation, and terminal care for patients. The non-healthcare direct cost however refers to the consumption of non-health related resources, such as travelling cost to and from health care providers, certain household expenses, costs related to relocation and loss of property, legal fees, and informal care from family or volunteers of the injured (Tarricone, 2006). Indirect Cost: Indirect costs refers to loss of productivity incurred as a result of an illness (Tarricone, 2006). The calculation of this category assumes and incorporates the incomes of the patient or the relative during the course of the disease, corresponds to the marginal product of labor. This has been suggested to also include sickness benefits (Anders et al, 2013). Indirect cost could be very substantial as many studies have suggested that estimated indirect costs could be three times higher than direct costs, accounting for up to 80% of total costs in patients (Xie et al., 2016). Intangible Cost: Intangible costs refers to psychosocial costs, such as pain,discomfort,fear and emotional suffering incurred by patients (Tarricone, 2006). Intangible costs are hardly ever quantified in COI studies because of difficulties and controversies related to its measurement (Jo, 2014).However, Xie et al. (2016) employed a contingent valuation method (CVM), based on the willingness to pay (WTP) approach to quantify intangible cost. 11 University of Ghana http://ugspace.ug.edu.gh 2.4.3 Types of Cost-of-Illness Studies The underlying aim of COI studies is to evaluate the economic burden of a disease on society as a whole (Jo,2014). There are three types of COI studies; prevalence versus incidence approach using epidemiological data, top down versus bottom-up approaches and retrospective versus prospective studies (Tarricone,2006). Prevalence versus incidence approach: It is the most commonly used approach in cost of illness studies where prevalence estimates the cost burden of illness or group of illnesses over a particular period, generally over a year, while the incidence approach estimates lifetime costs of a condition or group of conditions arising in a specified period of time (Jo,2014). The basic principle of the prevalence approach is that disease costs are assigned to the years in which they occur irrespective of the disease onset, whereas, with the incidence approach the disease costs are assigned to the year in which the disease first appears (Rice, 1994). Top down versus Bottom-up approach: The top-down approach measures the proportion of a disease or its risk factors (Jo,2014). It involves assignment of portions of a known total expenditure to each of several broad illness categories (Tarricone,2006). Cost estimation in the bottom-down approach involves two steps, with the initial step of estimating the amount of health inputs used and the second step involves estimating the unit costs of the inputs used (Tarricone,2006). The total costs are obtained through multiplication of the unit costs by the quantities used (Jo,2014). Prospective and retrospective studies: Another approach used in cost-of-illness analysis is using prospective and retrospective studies which depends on the relationship between the initiation of the study and data collection. In retrospective COI studies, all the pertinent events have already occurred by the time the study is initiated, and as such we just collect the data that were recorded 12 University of Ghana http://ugspace.ug.edu.gh earlier on (Jo,2014). Conversely, in a prospective study the relevant events have not already occurred by the time the study is initiated, hence data collection is done by following up the patients over time (Tarricone,2006). 2.4.4 Evaluation in Cost-of-Illness Studies Cost of illness studies seek to identify and measure all the costs of a particular disease and as stated by Jefferson et al(2000), "the aim of COI studies is to itemize, value, and sum the costs of a particular illness with the aim of giving an idea of its economic burden”. These studies are typically divided into two main categories. The first category is core costs, which are those relating directly to the disease and while the second category is non-health related costs, those resulting indirectly from the illness ( Rice, 1994). Each of these categories have direct costs within which payments are made, and indirect costs; for which resources are lost (Jo,2014). Estimates of direct cost of specific illnesses are comparatively straightforward, accurate and reliable (Tarricone,2006). Indirect and intangible cost estimates are associated with uncertainty and difficulty in its measurements, hence there are three major methods that are used; human capital approach, willingness to pay approach and friction cost method (Jo,2014). Human Capital Approach (HCA): In COI studies, human capital is defined as an individual’s productivity in society (Jo,2014.) In this approach lost earnings of individuals are taken as a proxy for lost productivity (Ratcliffe, 1995). It assumes that an individual’s future income can be used as a proxy for future productivity such that if he or she is absent from work, the future earnings lost can be equated to future production losses (Jo,2014).Even though this method is the commonest adopted in COI studies, it has some disadvantages. In this approach, life is valued as ‘market earnings’, as such it produces very low values for children and the elderly (Dorothy P. 13 University of Ghana http://ugspace.ug.edu.gh Rice, 2000). There is also another assumption that states, a worker cannot be replaced even if unemployment rate is high and in regards to this, the HCA overestimates the value of forgone production. (Jo,2014). Intangible costs, such as psychosocial costs which are components in the estimation of burden of illness are omitted in the human capital approach ( Rice, 2000). However, despite these problems listed above, the human capital approach is adopted by most COI researchers. Friction Cost Method: This method has been described as an alternative to the human capital approach, and estimates productivity losses as the short-term costs incurred by employers in replacing a lost worker (Riaz et al, 2016). According to this method, indirect costs for long-term absence mainly occur during the time, it takes, to replace a worker which is defined as the friction period (Johannesson & Karlsson, 1997). In using this method, it is presumed lower indirect cost estimates will be obtained than estimates based on the human capital approach and it provides a better reflection of the economic impact of illness (Koopmanschap et al., 1994).However, since the friction cost method assumes that productivity losses do not occur after the friction period, it is highly debatable among COI researchers and propose it is based on implausible assumptions not supported by neoclassical economic theory . Willingness-to-Pay Approach: This approach values life based on what individuals are willing or to pay in order to reduce the likelihood of illness or death( Rice, 2000).There are various ways of measuring this and they include conduction of surveys, examination of extra wages for high risk paying jobs, and examination of products demand that provide a higher level of health and safety. These methods are generally called Conjoint Analysis and the most common technique used in this group is the Contingent Valuation Method (Jo,2014). The Willingness-To-Pay approach of measuring indirect cost is influenced by the wealth of individuals and reveals their ability to bear 14 University of Ghana http://ugspace.ug.edu.gh risk in different circumstances, such that, adherence to these preferences directs government expenditures into curative programmes rather than on preventive and promotive programmes (Tarricone,2006). 2.4.5 Discounting and Sensitivity Analysis Discounting and Sensitivity analysis are used in many cost-of-illness studies to test the robustness of the studies because of the uncertainties associated with these studies. Discounting converts future currencies to their present value and is frequently applied when COI studies are carried out over a number of years(Molinier et al., 2008). Sensitivity analysis is a technique used to measure how different values of a key variable will have an effect on a particularly known variable under given conditions and assumptions (Jo,2014). It can take various forms: simple, multiway, and probabilistic (Molinier et al., 2008). 2.4.6 Applications of Cost of Illness Studies Cost-of-Illness studies provide useful information and provides a basis for decision making and policy formulation. Firstly, it tells us how much is spent on a particular disease in monetary terms and how much society saves when the disease is abolished which is known as the ‘cost savings’(Byford, 2000) .Secondly, it identifies the different elements of cost and the size of the contribution of each sector in society. This helps to determine research and funding priorities by highlighting areas where inefficiencies may exist and where savings can be made(Byford, 2000). They are also used to justify intervention programs and provide a basis for planning and policy formulation relative to prevention and control initiatives (Rice, 2000). Finally, they provide an economic framework for program evaluation( Rice, 2000). 15 University of Ghana http://ugspace.ug.edu.gh 2.4.7 Cost of Illness Studies for Domestic Violence Victims A variety of methodologies have been used in COI studies to calculate the costs associated with domestic violence victims. The commonest approach for estimating direct costs for domestic violence is the prevalence versus incidence approach as described above to determine the proportion of individuals that are using services as a result of domestic violence, the extent to which they use these services and the unit cost incurred by these victims (Duvvury et al,2012), Estimation of indirect costs is notoriously difficult to calculate when used in cost estimation among domestic violence victims (Walby, 2004)). The human capital approach is the most commonly used in estimation of indirect cost associated with domestic violence, even though, this method ignores pain and suffering which are important psychosocial costs associated with domestic violence (Miller et al,1994.). An alternative to this approach is the willingness to pay method, however there is little application of this method and would be extremely difficult to apply in developing countries(Duvvury et al., 2012). This method however takes into account the psychosocial costs associated with domestic violence when applied (Walby, 2004). 2.5 Conclusion As recommended by the World Health Organization Commission on Macroeconomics and Health, much more investment is needed to increase access to treatment while reducing the direct and indirect costs of illness and injuries to households(Conteh et al., 2002).The Human capital Approach was used in this study for calculating indirect costs as it provides a better estimate of the loss of future earnings that can be derived from the human resource lost as a result of domestic 16 University of Ghana http://ugspace.ug.edu.gh violence and therefore results obtained would therefore be essential in complementing social interventions in managing domestic violence in Ghana. 17 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE 3.0 METHODOLOGY 3.1 Study design The study was a retrospective, cross-sectional study, using costing studies to determine the cost of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra region, Ghana. As shown in Figure 2, the study adopted a fixed design, and a quantitative method in its design. Figure 2: Study design of the economic cost of domestic violence 18 University of Ghana http://ugspace.ug.edu.gh 3.2 Study area The Ledzokuku and Krowor districts initially known collectively as the Ledzokuku-Krowor Municipal Assembly (LEKMA), is served by a Domestic Violence and Victim Support Unit (DOVVSU), which is located at Teshie, the capital of LEKMA. DOVVSU is a function of the Ghana Police service which is aimed at providing support to victims of domestic and intimate partner violence. The total land area of Ledzokuku-Krowor Municipal district (LEKMA) is estimated at 50 square kilometers. The municipality is bounded to the south by the Gulf of Guinea (from the Kpeshie Lagoon to the Sakumono Junction). It continues along the railway line through Sakumono to the ‘on the run’ traffic light. It is bounded to the East by the Spintex Road towards the Coca Cola Roundabout. This turns to the left and right by Johnson Wax. To the north of the boundary is the Motorway through to the Tetteh Quarshie Interchange and moves south along the boundaries of the Ashitey Akomfra Electoral area and towards the estuary of the Kpeshie lagoon. Teshie- Nungua is a small town and is the capital of Ledzokuku-Krowor Municipal district, a district in the Greater Accra Region of Ghana. Figure 3 shows LEKMA wedged between the Accra Metropolitan Assembly on the west and Tema Metropolitan Assembly (TMA) on the East. 19 University of Ghana http://ugspace.ug.edu.gh Figure 3: Map of LEKMA 3.3 Study population The study participants consisted of individuals and households of individuals who have been victims of domestic violence from 1st February 2018 to 31st March 2019. These participants were residents of the Ledzokuku-Krowor Municipal district of Ghana. Inclusion criteria 1. Residents of LEKMA who reported of domestic violence within the period of study Exclusion criteria 1. Reported cases which were found to be false 2. Individuals who had illnesses or conditions that would not allow them to talk 3.4 Sample size calculation The sample size was calculated using the formula: 𝑍2 𝛼𝑃(1 − 𝑃) 1− 𝑛 = 2 𝑀𝑂𝐸2 Where n = sample size, Z = Z value (i.e., 1.96 for 95% confidence level); P= prevalence and MOE is the margin of error. Using the prevalence rate of 28% as the proportion of women suffering from domestic violence in Ghana (Ghana Statistical Services, 2016), n= 1.962 x 0.28(1-0.28) (0.10 x .28)2 n= 988 20 University of Ghana http://ugspace.ug.edu.gh Applying the finite population correction formula n= n˳ 1 + (n˳-1) 1 n= 230 Therefore, the minimum sample size for the study was 230 participants. This was based on the number of cases seen annually at the Kpeshie DOVVSU unit which was incorporated into the finite population correction to derive the minimum sample size. 3.5 Sampling method Desk review The LEKMA division of DOVVSU keeps all records of reported, and investigated cases of domestic and intimate partner violence. These records are kept with individual’s age, sex, contact, nature and description of reported assault, outcome of investigations as well as the individuals contact. A complete count of these records was done. Selection of participants From the complete records of the study period, a sampling scheme was obtained by dividing the total number of confirmed cases by the minimum sample size of 230. If the total number was less, or equal to 230, then all cases would be included in the study. On the other hand, with the obtained sampling scheme, a starting point was randomly selected by paper balloting in a bowl. This scheme was followed till a sample frame is obtained. The contacts of the obtained potential participants were retrieved, and then phone calls made to them. The purpose of the study was explained on phone, and individuals consecutively recruited to be part of the study only if she/he consented. The individuals were then given the option of visiting the DOVVSU premises at a convenient time to 21 University of Ghana http://ugspace.ug.edu.gh participate in the study or answering the questionnaire on phone at a convenient time. The participants alternatively gave directions to their houses for visits by members of the research team at a convenient time to conduct the interviews. 3.6 Study variables From the general records of DOVVSU, the following were obtained for all confirmed cases of domestic violence within the study period: age, sex, contact, nature and description of reported assault, outcome of investigations as well as the individuals contact. For the study participants however, socio demographic characteristics of each participant were obtained, including: age, sex, educational level, marital status, employment status, and monthly income. The dependent variable for this study were the total cost incurred/economic burden of domestic violence and the independent variables were: direct cost, indirect cost and intangible cost. Direct cost: This included medical and legal costs as well as non-medical/legal costs (i.e. cost of transport, food and consumables and communication) Indirect cost: This included productivity lost due to absenteeism from work, productivity lost due number of days caretakers had absented themselves from work and finally productivity lost due to travelling and waiting time. Intangible cost: Variables for intangible cost included pain, fear and emotional suffering. 22 University of Ghana http://ugspace.ug.edu.gh Table 1: Operational Definition and Measurement of the Variables Type of cost Category of cost Description (Average cost) Direct cost Medical cost 1. Cost of consultation 2. Cost of medication 3. Cost of diagnostics 4. Cost of hospitalizations Non-medical/Non-legal 1. Cost of travel 2. Cost of food 3. Other cost Legal 1. Cost of legal processes Indirect cost Cost of productivity loss 1. Productivity loss due to waiting time 2. Productivity loss due to travelling time 3. Days lost due to injury Intangible cost Intangible cost 1. Pain 2. Fear 3. Emotional Suffering 3.7 Data collection, techniques and tools Structured questionnaires, were employed for data collection. The questionnaire consisted of both open and closed ended questions covering relevant data on participant’s socio-demographic information. The questionnaire (Appendix 3) was in five (5) sections: the first part capturing the sociodemographic characteristics of the patient and coding information; the second part 23 University of Ghana http://ugspace.ug.edu.gh ascertaining direct cost, the third and fourth sections assessed variables for estimating indirect and intangible costs respectively. 3.8 Data analysis In pursuant of the objectives of the study, this constituted the background characteristics, estimation of direct, indirect and intangible costs. 3.8.1 Background characteristics This included the background characteristics of all the confirmed DV cases within the study period, as well as those of the study participants. These were represented descriptively with charts and tables. Central tendencies for continuous variables were reported with standard deviations, and proportions reported for categorical variables (marital status, educational status, employment status as well as average monthly income). 3.8.2 Estimation of direct cost This consisted of medical cost (e.g. medications, consultation, suturing of lacerations sustained as a result of violence), transportation, cost of legal processes, cost of food and consumables and additional medications. Medical costs: this consisted of medical costs incurred by the victims which included cost of medications, surgical interventions, laboratory investigations, and costs of consultation, costs of radiographs and other supportive treatment such as physiotherapy. Legal Processes: This consisted of legal fees paid for the services of lawyers as well as the costs incurred in procuring documents to start the legal procedures (e.g. costs incurred in signing police forms). 24 University of Ghana http://ugspace.ug.edu.gh Transport cost: this was the sum of the cost involved in conveying the patient to and from the hospital, police station and court house. Food and consumables cost: This consisted of the sum of the cost of food and drinks as well as other consumables that the victims consumed in the period of admission in the hospital, or during visits to the police station and law courts. Miscellaneous: This consisted of the sum of unaccounted for costs which included communication, photocopies of documents and other transactions that occur as result of the legal and medical processes. The total direct cost was calculated by summing up all the costs of surgical interventions, medical, legal processes and the components of non-medical and non-legal related costs. 3.8.3 Estimation of Indirect Costs Indirect cost was estimated by multiplying the daily minimum wage rate by the number of workdays lost to the victim and other family members. The national minimum wage for the year 2019 which is GHS 10.65 per day was used to determine productivity loss. The estimation of indirect cost is shown in Table 2. Table 2. Estimation of Indirect cost No. Category Cost Estimation Approach 1 Days lost to victim This would be the summation of days lost to victims due to injury per month 2 Days lost to victims’ relatives/household members This would be the summation who accompany them for medical and legal of the total number of days lost processes to victims’ relatives/ 25 University of Ghana http://ugspace.ug.edu.gh household members as a result of medical and legal processes 3 Productivity loss due to travelling and waiting This would be the summation times of the total number of hours spent by the victim as well as relatives who accompany them for medical and legal procedures 4 Total Indirect Cost This would be the overall calculation of the total productivity loss multiplied by the daily minimum wage 3.8.4 Estimation of Intangible costs Intangible cost was estimated using a Likert scale to measure the effect of domestic violence on the victims and their households, a tool adopted from (Blankson, 2017). The tool consists of a five- dimension Likert scale of 1)’not at all’ 2) ‘a little’ 3) ‘moderately’ 4)’quite a bit’ 5)’extremely’ in the domains of intangible costs made up of pain, fear and emotional suffering. The composite intangible score was obtained by adding the dimensions in each domain and multiplying by the number of questions after which the score was reclassified into low, moderate and high intangible costs. The composite intangible score with their corresponding ranges are shown in table 2. 26 University of Ghana http://ugspace.ug.edu.gh Table 3. Composite Intangible Score No. Dimension Upper range limit 1. Low 1/3(11-26) 2, Moderate 2/3(27-37) 3. High 3/3(38-55) 3.9 Quality control Adequate measures were put in place to safeguard and guarantee data accuracy and quality thereby minimizing bias. These measures included training of research assistants, pretesting of questionnaires, editing of completed questionnaires and data entry. All completed questionnaires were validated weekly before data entry. After the entry process, data was cleaned before the analysis was done. Completed questionnaires were kept under lock and key. Two research assistants with basic knowledge of domestic violence were engaged and trained prior to the administration of questionnaires. They were trained for a period of two days on how to administer the questionnaires, how to obtain consent and how to handle the information collected. The questionnaire was pretested at the Kpeshie Domestic Violence and Victim Support Unit. All errors and inconsistencies encountered during the pretest were corrected before actual commencement of the study. Completed questionnaires were screened thoroughly, validated and coded within 24 hours of data collection. Data was double checked before entry into Microsoft Excel 2013. 3.10 Sensitivity Analysis To test for robustness of the costs, estimated one way and multi-way sensitivity analysis were done by varying relevant cost components. The components on which the sensitivity test were 27 University of Ghana http://ugspace.ug.edu.gh conducted on were medication and wage. These components were selected because of the uncertainty associated with them. The test was performed by increasing the two components by 3% and 5% respectively. 3. 11 Ethical considerations 3.11.1 Ethical Clearance Ethical approval was sought from the Ghana Health Service Ethical Review Board before commencement of the study. The study was carried out at the premises of the Kpeshie Domestic Violence and Victim Support Unit. 3.11.2 Approval from Study Area Approval was also sought from the administrational hierarchy of the DOVVSU of the Ghana Police service. 3.11.3 Description of Subjects in the Study Participants of this study were married or cohabiting women 18years and above who have been victims of domestic violence 3.11.4 Potential Risk/Benefit Though the participants may not have any immediate or direct benefits from the study, their responses would be helpful in policy planning and formulation of recommendations to appropriate authorities concerning domestic violence. There was no anticipated risk or harm from the study. The only inconvenience, was the time spent in the interview. In view of this, the design of the questionnaire (Appendix 3) was well structured to facilitate the discourse. The respondents were told about the general nature of the study and assured of no potential harm during the study. 28 University of Ghana http://ugspace.ug.edu.gh 3.11.5 Privacy and Confidentiality The Principal Investigator ensured that the interviews were conducted in a secure place free from interaction of other on-going activities. The participation to these interviews were voluntary. Participants were informed of their right to stop and opt out of the interview at any point during the process. 3.11.6 Data Storage and Usage All files, papers and data obtained from the study were locked in a cabinet and on computers protected by passwords. Electronic data files were stored on an external drive with a secured password with access limited to only the principal investigator and supervisor. Research assistants did not have access to these documents except when granted permission by either the principal investigator and /or supervisor. Data files were kept for six months after which they were destroyed. 3.11.7 Description of Consenting Process Consent of participants was obtained before data was collected. An information sheet was read out to participants. In this sheet, the potential benefit of the study to participants and the country were outlined. This was done through thumb printing or signing of a consent form. The purpose of the study, the benefits and rights of the subjects and the procedure involved were explained to all participants prior to the interview. They were assured of confidentiality and a voluntary informed consent will be obtained from all participants. 3.11.8 Voluntary Withdrawal There were no consequences, like loss of benefit or care to the participants if they chose to withdraw from the study. Please note that some of the information already obtained before you chose to withdraw from the study may have been used in analysis already. This data cannot be 29 University of Ghana http://ugspace.ug.edu.gh linked to your name and may be used in study reports and publications as the total number of people who refused to participate. 3.11.9 Compensation There was no compensation for participants participating in this study. 3.11.10 Declaration of Conflict of Interest The Principal Investigator had no conflict of interest in this study. 3.11.11 Proposal and Funding Information The Principal Investigator self-funded this study. 30 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR 4.0 RESULTS 4.1 Background characteristics of respondents There were a total number of 120 respondents, all being females who participated in this study. The mean and median ages were 32.2 (±6.5) and 31 years respectively (Table 4). Most respondents that were interviewed fell between the age group of 18 to 35 years making up 71.7% (83) of the respondents that were interviewed. Most of the participants that were interviewed had at least some basic education with the majority,47% (57) having Secondary School/Vocational or Technical Training. Only 4% (5) of the women interviewed had no formal education (Table 4). Majority of the respondents 73% (88) were employed, 25% (22) worked in the formal sector, while 75% (66) worked in the informal sector. Of 120 respondents, 16% (19) of them were unemployed, however the majority of these people had been looking for a job over the past six months. Most of the respondents,69.2% (83 had insured with NHIS. The average duration of marriage or cohabitation was 2.03 (±0.78) years, while the average number of children of participants was 2 (±1). The average monthly salary of all the respondents was GHS 455.05 (± 314.97), the salary did not, however, vary significantly among the work sectors (P=0.073). For the 28 respondents who indicated that they received remittances, the average amount received was GHS 139.36 (±71.70) 31 University of Ghana http://ugspace.ug.edu.gh Table 4: Background characteristics of respondents Variable Number Percent Age 18 to 35 86 71.7 Above 35 34 28.3 Education No education 5 4.0 Primary 12 10.0 Middle/Secondary/ 27 22.0 SSS/SHS/Secondary/Vocational/Technical 56 47.0 Tertiary 20 17.0 Marital status Single 17 14.2 Married 48 40.0 Co-habiting 48 40.0 Divorced 3 2.5 Separated 4 3.3 Employment status Employed 88 73.0 Unemployed 19 16.0 Student 6 6.0 Housewife 5 4.0 Retiree 1 1.0 Employment Sector Formal Sector 22 25 Informal Sector 66 75 NHIS Beneficiary 83 69.2 Non-Beneficiary 37 30.8 32 University of Ghana http://ugspace.ug.edu.gh 4.2 Total Cost of Domestic Violence The total direct cost of domestic violence against women who participated in this study was GHS 73,017.33 (USD13,725.06). The average total cost of Domestic violence from the study was estimated to be GHS 562.12 (USD 98.89) of which the direct cost was made up of 60% and the indirect cost was 40% (Figure 4). Most of the direct cost was attributed to medical expenses with a total cost of GHS 58,868.50(USD 11065.51) and an average expenditure of GHS 255.95 (USD48.11) per household annually, the bulk of this was from consultation/registration fees. The average direct cost of domestic violence from the study was estimated at GHS 317.47(USD 59.67), as shown in Table 5. Travel cost was the major non-medical cost incurred by respondents in the study constituting a total of GHS 9506.67(USD 1786.97) and an average of GHS 41.33 (USD7.77) per household annually. This was higher than non-medical costs of food and drinks which cost an average of GHS 13.00 (USD2.44) and GHS 3.00 respectively (USD 0.57) and a total of GHS 3687.67(USD 693.17)The miscellaneous or other cost that contributed to the non- medical and legal fees were phone call credit and other processing fees that were paid by the respondents. The ratio of the medical cost to that of the non-medical and legal cost was about 4:1 emphasizing the huge cost contribution of the medical cost to the total direct cost. As shown in Table 5, the greatest portion of indirect cost was attributed to time lost by caregivers’ with time lost with traveling and waiting time contributing to the next proportion. The total indirect cost was estimated at GHS 47,988(USD 9020.37) with the ratio of direct to indirect cost was 1.5:1 (Table 6). 33 University of Ghana http://ugspace.ug.edu.gh Indirect USD 39.22, 40% Direct, USD 59.67, 60% Figure 4: Cost Profile of Domestic Violence 34 University of Ghana http://ugspace.ug.edu.gh Table 5: Total Household Cost of Domestic Violence COST COMPONENT GHS USD Cost Profile (%) Direct Cost Medical Registration/Consultation 46609.50 8761.18 38.52 Medication 8770.67 1648.62 7.25 Labs and Images 3488.33 655.70 2.88 58868.50 11065.51 48.65 Non-medical and legal Travel 9506.67 1786.97 7.86 Food 2990.00 562.03 2.47 Drinks 697.67 131.14 0.58 Others 954.50 179.42 0.79 Sub total 14148.83 2659.56 11.69 Total Direct Cost 73017.33 13725.06 60.34 Indirect Cost Valued Productivity Time lost 5510.80 1035.86 4.55 Value Travel and Waiting Time Lost 18227.50 3426.22 15.06 Value Caregivers Time Lost 24250.05 4558.28 20.04 Sub total 47988.35 9020.37 39.66 TOTAL COST 121005.68 22745.43 100.00 US$1.00 equivalent to GHS 5.32 (BOG average monthly interbank exchange rate, June 2019) 35 University of Ghana http://ugspace.ug.edu.gh Table 6. Average Cost of Domestic Violence Cost Profile COST COMPONENT GHS SD USD SD (%) DIRECT COST Medical Registrations/Consultation 202.65 30.13 38.09 5.66 38.52 Medication 38.13 50.40 7.17 9.47 7.25 Labs and Images 15.17 162.71 2.85 30.58 2.88 Sub Total 255.95 81.08 48.11 15.24 48.65 Non-medical and legal Travel 41.33 16.30 7.77 3.06 7.86 Food 13.00 8.88 2.44 1.67 2.47 Drinks 3.03 3.28 0.57 0.62 0.58 Others 4.15 3.27 0.78 0.61 0.79 Sub Total 61.52 31.73 11.56 5.96 11.69 Total Direct Cost 317.47 112.81 59.67 21.20 60.34 INDIRECT COST Valued Productivity Time lost 23.96 16.06 4.50 0.85 4.55 Value Travel and Waiting Time Lost 79.25 30.12 14.90 2.80 15.06 Value Caregivers Time Lost 105.44 85.03 19.82 3.73 20.04 Total Indirect Cost 208.65 131.21 39.22 7.37 39.66 TOTAL AVERAGE COST 526.12 244.02 98.89 18.59 100.00 US$1.00 equivalent to GHS 5.32 (BOG average monthly interbank exchange rate, June 2019) 36 University of Ghana http://ugspace.ug.edu.gh 4.3 Intangible cost The study assessed the level of fear, pain and emotional suffering as perceived by the participants (Figure 5) as the intangible cost among domestic violence victims.The study observed a high intangible cost amongst domestic violence victims of 89%(107) whiles only 11%(13) of them suffered intangible cost in the medium or moderate range (Figure 5) . Medium 11% High 89% Figure 5: Intangible cost of Domestic Violence Victims However, there was a significant difference (Table 7) between educational status and the likelihood of incurring a high intangible cost(p=0.005), but no significant difference in incurring intangible cost by age(p=0.016),marital status(p=0.714) nor employment status(p=0.808). 37 University of Ghana http://ugspace.ug.edu.gh Table 7: Association of high intangible cost with background characteristics Variable High Intangible X2 P-value cost Age 5.764 0.016 18 to 35 73 Above 35 34 Education 14.843 0.005 No education 5 Primary 11 Middle/Secondary/ 25 SSS/SHS/Secondary/Vocational/Technical 53 Tertiary 13 Marital status 2.116 0.714 Single 14 Married 42 Co-habiting 44 Divorced 3 Separated 4 Employment status 1.606 0.808 Employed 78 Unemployed 18 Student 5 Housewife 5 Retiree 1 4.4 Sensitivity analysis As shown in Table 8, one-way sensitivity analysis conducted by varying the cost of medication by 3% and 5 % respectively yielded 2.4% and 7.7% increase in the total treatment cost. The same analysis was conducted on wage rate and yielded 7.7%. Variations in medication of 3% and 5% yielded no change in direct costs as well as indirect costs. However, the same level of variations in wage rate yielded a 0.1% increase in direct cost. Multi-way sensitivity analysis of both medication and wage rate by 3% and 5% resulted in a 2.3% and 3.9% increase in total treatment cost respectively. However, concurrent variations in both wage and rate by 3% and 5% resulted in a percentage rise in direct cost and thus a fall in percentage of indirect cost. 38 University of Ghana http://ugspace.ug.edu.gh Table 8. Sensitivity Analysis of Total Cost Scenario Cost %change Total cost Percentage Proportion of Percentage Component in change in total cost change in parameter total cost proportions of cost GHS USD Direct Indirect Direct Indirect Base scenario 0 73,224.96 0.0 99.7 0.3 0 0 16,794.72 Variation (One-way Sensitivity Medication 3 74,991.02 2.4 99.7 0.3 0.0 0.0 A 1 nalysis) 17,199.77 5 76,168.39 4.0 99.7 0.3 0.0 0.0 17,469.81 Variation (One-way Sensitivity Wage rate2 3 78,862.79 7.7 99.8 0.2 0.1 -0.1 Analysis) 1 18,087.80 5 78,865.56 7.7 99.8 0.2 0.1 -0.1 18,088.43 Multi-variation (Multi-way Medication 3 74,925.51 2.3 99.8 0.2 0.1 -0.1 Sensitivity Analysis) 1 and Wage 17,184.75 rate 5 76,105.65 3.9 99.8 0.2 0.1 -0.1 17,455.43 US$1.00 equivalent to GHS 5.32(Bank of Ghana average monthly interbank exchange rate, June 2019) 1The cost of medication and wage rate was independently and concurrently varied by 3% and 5% increment. 2The national minimum wage per day of GHS10.65 as at June, 2019 was used to value productivity days and time lost to patients 39 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE 5.0 DISCUSSION The objective of this study was to determine the direct, indirect and intangible cost that female victims of domestic violence incur in the Ledzokuku and Krowor districts of the Greater Accra Region of Ghana. The average direct and indirect costs were estimated at GHS 317.47 (USD59.67) and GHS 208.65(USD 39.22) respectively. The total cost estimated for both direct and indirect cost was GHS 121005.68(USD22,745.43) representing 60% and 40% of the direct and indirect cost respectively. The study found that most of the respondents of the study had high intangible cost representing 89% of the total and medium/moderate intangible cost representing 11% of responses. The study also sought to find out some of the determinants of domestic violence particularly looking at age, employment status and level of education as some of the major contributors of domestic violence in the area. 5.1 Socio-demographic factors and exposure to domestic violence The study reports a greater occurrence of domestic violence among women within the young adult age group (18 to 35 years) which was consistent with the Ghana Family Life and Health survey and studies done in the United States which showed that women between the age of 18-24 years are more likely to be victims of domestic violence at the hands of a partner (Huecker & Smock, 2019). This could be explained by the fact that most of these women enter into relationships with their spouses at an early age considering the average duration of marriage or cohabitation was estimated at 2 to 3 years. This could also be explained by the fact that women in this age group are 40 University of Ghana http://ugspace.ug.edu.gh more likely to report issues of domestic violence as compared to those of the older age group (35 years and above) (Huecker & Smock, 2019). This study finds out that most of the victims had secondary, vocational or technical training which is contradictory with literature which attributes tertiary levels of education, such as degree holders as a significant predictor of domestic violence and therefore predisposing them to higher incidences of domestic violence (Bonnes, 2016). This stems from the fact that women with higher levels of education are economically independent and as such face the likelihood of domestic violence. However, even though from the study most of the respondents were employed most of them worked in the informal sector with an average salary of GHS 455.05(USD 85.53). Comparing this to the monthly minimum wage in the country which is GHS 287.55(USD54) (WageIndicator Foundation, 2019) most of the participants earned about one and half times the monthly minimum wage. The average total direct cost obtained from this study was GHS 317.47(USD59.67) and comparing this to the average salary of the respondents it can be deduced that about 70% of their salary is spent on domestic violence. The non-response rate of this study was about 50% which could be explained by the fact that issues of domestic violence are sensitive especially when clients are interviewed over the phone or called for an interview, this is consistent with surveys which involve domestic violence victims in which a non-response rate as high as 72% has been recorded(McNutt & Lee, 2000). 5.2 Direct Cost This study investigated the cost incurred by victims of domestic violence in these two districts of Accra so as to provide information for possible decision making to reduce the cost burden incurred by these victims. The direct cost of this study is estimated at GHS 73,017.33(USD 13,725.06) with 41 University of Ghana http://ugspace.ug.edu.gh most of it being attributed to the medical cost with an average of GHS 255(USD 48.11) being spent per household annually. The bulk of this amount was from registration and consultations. The direct cost component of the legal fees could not be captured because most of these cases are settled out of court which is consistent with a study done in Ghana by (Adu Gyamfi, 2014) which concludes that domestic violence is seen as a private family issue and should be settled privately “outside” the judiciary system. Comparing this to a study done in Vietnam on the costs of domestic violence, the average direct medical cost for the respondents was reported as high with a cost estimate of VND 252,000(USD 10.6) per household for Vietnamese victims, however, most of the services provided by district health facilities were free as they were borne by the government in the country as compared to those that ended up in Tertiary centers(Duvvury et al., 2012).A study done in Nigeria reported an average direct cost of USD 35.64 for direct medical costs associated with road traffic injuries (Juillard et al, 2010) which favourably compares to this study which determined the average direct cost of injury to be USD 48.11. The non-medical and legal component of the direct cost was contributed largely by travel cost with an average of GHS 41.33(USD 7.77). 5.3 Indirect Cost The indirect cost of domestic violence was determined by using the human capital approach which employed the use of the daily minimum wage rate multiplied by the days lost to victim and other family members. The total indirect cost of the study is estimated at GHS 47,988(USD 9020.37) which is 40% of the total cost. The study shows that the major contributor to indirect cost was due to productivity lost to both the caregiver and the victim which is estimated at an average of GHS 129.4 (USD24.32) and a total of GHS 29760.8 (USD5594.13).This is comparable to a similar study carried out by Blankson (2017) in Ghana, on household cost of injuries specifically road 42 University of Ghana http://ugspace.ug.edu.gh traffic accidents in which the major contributor to indirect cost was productivity lost to both the victims and their caregivers. Comparatively the cost estimate for productivity lost to both victims and caregivers in Blankson’s study was GHS 230,647(USD53,022) which is higher than the estimate obtained in this study, however, it emphasizes the cost contribution of productivity losses to both the victim and the caregiver. Morrison and Orlando (1999) conducted similar studies in Chile and Nicaragua which extrapolated the loss of productivity to victims of domestic violence to be USD 1.73 billion and USD 32.7 million respectively equivalent to 1.6% of Chilean’s GDP,78.04 billion USD and 2% of Nicaraguan’s GDP, 4.308 billion USD. The average indirect cost obtained in this study is GHS 208.65(USD 39.22) comparing this to an average income of 455.05(USD 85.53) this means productivity losses constitute about half of their revenue generated. Even though this is not significant to contribute to the country’s GDP, this poses a significant loss of earnings to these domestic violence victims and their caregivers. 5.4 Intangible Cost Studies done on costs of domestic violence have found that the consequences do not only involve goods or services rendered but are intangible in nature and such costs are important in the measurement of overall cost (Day et al., 2005). For example (Morrison & Orlando, 1999) concluded that it is important to estimate intangible costs such as pain and emotional suffering which are pertinent for policy makers to address social problems. This study used a Likert scale to determine intangible cost a tool adopted from Blankson (2017) which determined the intangible cost without a costing component. Most of the respondents (89%) had a high proportion of fear, pain and emotional suffering which was expected and consistent 43 University of Ghana http://ugspace.ug.edu.gh with studies carried out by (Cerulli et al, 2012) which showed that victims of domestic violence suffer from high levels of emotional and psychological pain resulting in the prevalence of psychiatric disorders such as depression and post-traumatic stress disorders. As such victims of domestic violence require psychological counselling to enable them go through the trauma sustained as it sometimes becomes a social stigma in their lives (Rakovec-Felser, 2014). Limitations of the study The non-response rate of the study was about 50% and could be attributed to the fact that during the study period the number of cases reported were low and the nature of the study involves victims of domestic violence which is a sensitive issue and as such some of these victims are reluctant to share their experiences. Recall of information regarding the time of injury as well as the cost involved may not have been entirely accurate and as such misreporting cannot be ruled out. The time allotted for collecting data was a constraint in the study, on the basis that some of the victims had to report to the health facilities before reporting back to the police station and some of these victims never came back at the time the study was being completed. In addition to this, those who were called for interviews also had busy schedules to attend to, at the time the study was being conducted and could not make time to meet when the study was being concluded. The above reasons could also be a factor for the non-response rate. 44 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX 6.0 CONCLUSION AND RECOMMENDATION 6.1 CONCLUSION This study provides an insight to the cost burden of domestic violence against women highlighting that both direct and indirect costs contribute significantly to the burden. The study shows that age and educational status are major contributors to the occurrence of domestic violence in the Ledzokuku and Krowor districts of the Greater Accra Region, with a high incidence among the young adult ages (18 – 35 years) and those with secondary, vocational or technical training. The study also shows the average cost of domestic violence to be 562.12 (USD 98.89) per victim which implies a significant cost burden to victims with the bulk of this expenditure on health. It also shows that victims of domestic violence suffer from high levels of fear, pain and emotional suffering. In conclusion, enforcing policies that prevent domestic violence against women could improve the socio-economic status of women and also avoid health care expenditures. 6.2 RECOMMENDATION The following recommendations are made from this study 1. Cost of domestic violence should be made public and offenders should be made to pay. 45 University of Ghana http://ugspace.ug.edu.gh 2. The unit costs obtained in this study could be used in budget allocation for victims of domestic violence 46 University of Ghana http://ugspace.ug.edu.gh REFERENCES Adu Gyamfi, E. (2014). Challenges Undermining Domestic Violence Victims’ Access to Justice in Mampong Municipality of Ghana. Journal of Law, Policy and Globalization, 27(0), 75- 90–90. Africa, W., Works, W., & Three, C. (2017). Working Paper No . 4 - Ghana : The Economic and Social Impact of Violence Against Women and Girls ( VAWG ). Akazili, J., McIntyre, D., Kanmiki, E. W., Gyapong, J., Oduro, A., Sankoh, O., & Ataguba, J. E. (2017). Assessing the catastrophic effects of out-of-pocket healthcare payments prior to the uptake of a nationwide health insurance scheme in Ghana. Global Health Action, 10(1). https://doi.org/10.1080/16549716.2017.1289735 Anders B, Ommen O, Pfaff H, Lüngen M, Lefering R, Thüm S, et al. (2013). Direct , indirect , and intangible costs after severe trauma up to occupational reintegration – an empirical analysis of 113 seriously injured patients Direkte , indirekte und intangible Kosten nach einem schweren Trauma. GMS Psychosoc Med, 10(02), 1–15. https://doi.org/10.3205/psm000092 Asante, F., Fenny, A., Dzudzor, M., Chadha, M., Scriver, S., & Ballantine, C. (2019). Economic and Social Costs of VAWG,Ghana. North. Australia. Office of the Status of Women., Access Economics (Firm), & Partnerships Against Domestic Violence (Australia). (2004). The cost of domestic violence to the Australian economy : [a report. [Office of the Status of Women]. Blankson, P.-K. (2017). DEPARTMENT OF HEALTH POLICY PLANNING AND MANAGEMENT HOUSEHOLD COSTS OF INJURIES: A CASE STUDY OF THE CASUALTY AND ACCIDENT CENTRE OF KORLE-BU TEACHING HOSPITAL. Bonnes, S. (2016). Stephanie Bonnes, MA, PhD(c), 31(1), 51–71. Byford, S. (2000). Economic Note: Cost of illness studies. Bmj, 320(7245), 1335–1335. https://doi.org/10.1136/bmj.320.7245.1335 Center for Research on Women International. (2008). Estimating the Costs and Impacts of 47 University of Ghana http://ugspace.ug.edu.gh Intimate Partner Violence Estimating the Costs and Impacts of Intimate Partner Violence Estimating the Costs and Impacts of Intimate Partner Violence Estimating the Costs and Impacts of Intimate Partner Violence in Deve. Retrieved from https://www.icrw.org/wp- content/uploads/2016/10/Estimating-the-Costs-and-Impacts-of-Intimate-Partner-Violence- in-Developing-Countries-A-Methodological-Resource-Guide.pdf Cerulli, C., Poleshuck, E., Raimondi, C., Veale, S., & Chin, N. (2012). “What Fresh Hell Is This?” Victims of Intimate Partner Violence Describe Their Experiences of Abuse, Pain, and Depression. Journal of Family Violence, 27(8), 773–781. https://doi.org/10.1007/s10896-012-9469-6 City, N. Y. (2008). I Ntimate P Artner V Iolence, (July), 1–39. Conteh, L., Corrao, M., Hanson, K., Kumaranayake, L., Libatique, D., Kurowski, C., … Galvez Tan, J. Z. (2002). Improving Health Outcomes of the Poor. World Health Organisation. Damenshie-Brown, R. (2013). Domestic Violence Against Women in Ghana. Day, T., Mckenna, K., & Bowlus, A. (2005). United Nations Nations Unies. Duvvury, N., Grown, C., & Redner, J. (2000). Costs of Intimate Partner Violence at the Household and Community Levels: An Operational Framework for Developing Countries. Duvvury, N., Minh, N. H., & Carney, P. (2012). ESTIMATING THE COSTS OF DOMESTIC VIOLENCE AGAINST WOMEN. Ellsberg, M., Jansen, H. A. F. M., Heise, L., Watts, C. H., & García-Moreno, C. (2008). Intimate partner violence and women’s physical and mental health in the WHO multi-country study on women’s health and domestic violence : An observational study. The Lancet, 371, 1165– 1172. https://doi.org/10.1016/s0140-6736(08)60522-x Fourozan, A. S., Dejman, M., Baradaran-Eftekhari, M., & Bagheri-Yazdi, A. (2007). A study on direct costs of domestic violence against women in legal medicine centers of Tehran (2002). Archives of Iranian Medicine, 10(3), 295–300. https://doi.org/07103/AIM.004 Garcia-Moreno, C., & Watts, C. (2011). Violence against women: An urgent public health priority. Bulletin of the World Health Organization. https://doi.org/10.2471/BLT.10.085217 48 University of Ghana http://ugspace.ug.edu.gh Huecker, M., & Smock, W. (2019). Huecker MR, Smock W. Florida Domestic Violence. [Updated 2019 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK493194/No Title. Institute of Development Studies (IDS), Ghana Statistical Services (GSS), & Associates. (2016). Domestic Violence in Ghana: Incidents, attitudes, determinants and consequences. Retrieved from http://www.statsghana.gov.gh/docfiles/publications/DV_Ghana_Report_FINAL.pdf Jo, C. (2014). Cost-of-illness studies: concepts, scopes, and methods. Clinical and Molecular Hepatology, 20(4), 327–337. https://doi.org/10.3350/cmh.2014.20.4.327 Johannesson, M., & Karlsson, G. (1997). The friction cost method : A c o m m e n t, 16, 249– 255. Juillard, C., Labinjo, M., Kobusingye, O., & Hyder, A. A. (2010). Socioeconomic impact of road traffic injuries in west Africa: Exploratory data from Nigeria. Injury Prevention, 16(6), 389–392. https://doi.org/10.1136/ip.2009.025825 Koopmanschap, M. A., Van Roijen, L., Bonneux, L., Bonsel, G. J., Rutten, F. F. H., & Van Der Maas, P. J. (1994). Cost of diseases in international perspective. European Journal of Public Health, 4(4), 258–264. https://doi.org/10.1093/eurpub/4.4.258 Laing, L., & Bobic, N. (2002). Literature Review: Economic costs of domestic violence. Manyazewal, T. (2017). Using the World Health Organization health system building blocks through survey of healthcare professionals to determine the performance of public healthcare facilities. Archives of Public Health, 75(1). https://doi.org/10.1186/s13690-017- 0221-9 McNutt, L. A., & Lee, R. (2000). Intimate partner violence prevalence estimation using telephone surveys: Understanding the effect of nonresponse bias. American Journal of Epidemiology, 152(5), 438–441. https://doi.org/10.1093/aje/152.5.438 Miller, T. R., Cohen, M. A., & Rossman, S. B. (n.d.). Victim Costs Of Violent Crime And Resulting Injuries by Ted R. Miller, Mark A. Cohen, and Shelli B. Rossman. 49 University of Ghana http://ugspace.ug.edu.gh Molinier, L., Bauvin, E., Combescure, C., Castelli, C., Rebillard, X., Soulié, M., … Grosclaude, P. (2008). Methodological considerations in cost of prostate cancer studies: A systematic review. Value in Health, 11(5), 878–885. https://doi.org/10.1111/j.1524-4733.2008.00327.x Morrison, A., & Orlando, M. (1999). Social and Economic Costs of Domestic Violence:Chile and Nicaragua. Oice, W. O. S. V, Gency, A., Eries, P. A. R. E. S., & Aoife, N. (2013). W OMEN ’ S V OICE , A GENCY , & P ARTICIPATION R ESEARCH S ERIES 2013 N O . 3 ARTNER V IOLENCE : FOR AND AND FOR. Rakovec-Felser, Z. (2014). Domestic violence and abuse in intimate relationship from public health perspective. Health Psychology Research, 2(3). https://doi.org/10.4081/hpr.2014.1821 Ratcliffe, J. (1995). The measurement of indirect costs and benefits in health care evaluation: A critical review. Project Appraisal, 10(1), 13–18. https://doi.org/10.1080/02688867.1995.9726969 Riaz, N., Wolden, S. L., Gelblum, D. Y., & Eric, J. (2016). HHS Public Access, 118(24), 6072– 6078. https://doi.org/10.1002/cncr.27633.Percutaneous Rice, D P, Hodgson, T. A., & Kopstein, A. N. (1985). The economic costs of illness: a replication and update. Health Care Financing Review, 7(1), 61–80. Rice, Dorothy P. (2000). Cost of illness studies: What is good about them? Injury Prevention, 6(3), 177–179. https://doi.org/10.1136/ip.6.3.177 Rice, Dorothy P. (1994). Cost-of-illness studies : fact Single-dose antibiotic treatment for travellers ’ diarrhoea. The Lancet, 344(desember), 1519–1520. Retrieved from http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(94)90342-5/abstract Shuib, R., Endut, N., Ali, S. H., Osman, I., Abdullah, S., Oon, S. W., … Shahrudin, S. S. H. (2013). Domestic Violence and Women’s Well-being in Malaysia: Issues and Challenges Conducting a National Study Using the WHO Multi-country Questionnaire on Women’s Health and Domestic Violence Against Women. Procedia - Social and Behavioral Sciences. https://doi.org/10.1016/j.sbspro.2013.08.445 50 University of Ghana http://ugspace.ug.edu.gh Tarricone, R. (2006). Cost-of-illness analysis What room in health economics? Health Policy, 77, 51–63. https://doi.org/10.1016/j.healthpol.2005.07.016 WageIndicator, F. (n.d.). No Title. Retrieved from https://mywage.org/ghana/salary/minimum- wages Walby, S. (2004). The Cost of Domestic Violence, (September). WHO-CHOICE. (2003). Making choices in health: WHO guide to cost-effectiveness analysis. Global Programme on Evidence for Health Policy ,World Health Organization, Geneva, 71. https://doi.org/10.1590/S1135-57272004000300012 World Health Organisation. (2017). Violence against womenNo Title. Retrieved September 29, 2018, from http://www.who.int/news-room/fact-sheets/detail/violence-against-women Xie, F., Thumboo, J., Edin, F., Fong, K., Edin, F., Lo, N., & Edin, F. (2016). A Study on Indirect and Intangible Costs for Patients with Knee Osteoarthritis in Singapore A Study on Indirect and Intangible Costs for Patients with Knee Osteoarthritis in Singapore, (October). https://doi.org/10.1111/j.1524-4733.2008.00371.x 51 University of Ghana http://ugspace.ug.edu.gh APPENDIX 1 INFORMATION SHEET School of Public Health College of Health Sciences University of Ghana Title of Study: ECONOMIC BURDEN OF DOMESTIC VIOLENCE IN THE LEDZOKUKU AND KROWOR DISTRICTS OF THE GREATER ACCRA REGION, GHANA Introduction: My name is John Baptist Amissah and I am a student pursing a Master of Public Health Degree in the School of Public Health, University of Ghana, Legon. I am the principal investigator on this study. Background and Purpose of research: Violence against women is considered a violation of their basic fundamental human rights. WHO reports that at least 1 in three women have experienced some form of physical or sexual abuse at some point in their lifetime(Oice et al., 2013). It has a major impact on the health status of the woman leading to low productivity, high cost of treatments (legal, hospital and law enforcement expenses) and indirect cost to other family members. The purpose of this study therefore is to determine the economic burden of domestic violence in two districts in the Greater Accra Region. The study is expected to highlight the cost burden of domestic violence on victims and to help in the formulation of policies and provision of support and rehabilitation services for these victims Nature of research: You are invited to take part in this study. I am interested in finding the total costs that victims of domestic violence incur when the incident occurs. It is a quantitative study 52 University of Ghana http://ugspace.ug.edu.gh and it will involve 230 victims of domestic violence (married or cohabiting women aged 18years and above). The study will be done at the Kpeshie Domestic Violence and Victim Support Unit. Participants’ involvement: • Duration /what is involved: If you agree to take part in this study, you will be asked to fill out a questionnaire which will take about 30 minutes of your time • Potential Risks: The study poses no serious risk to any participant. • Benefits: There may be no direct benefit to the participant, however data generated could be used to highlight the cost burden victims of domestic violence face and assist in formulation of policies and provision of support and rehabilitation services for these victims. • Costs: Participation will come at no cost to respondent • Compensation: Participants who agree to take part in the study will not be given any monetary or non-monetary compensation • Confidentiality: All information provided by the respondents will be kept confidential. Names and identities of interviewees will not be needed for the study. The information provided will only be identified by a code number and treated with strict confidentiality. The name of interviewees will not appear or be mentioned in any part of the report of the study. Interview process will be used to obtain information from interviewees and the principal investigator will ensure that they are not exposed to any form of risks • Voluntary participation/withdrawal: Taking part in this study is wholly voluntary. You may skip any question that you do not want to answer. Also you are permitted to withdraw from the study at any time; there will be no consequence for doing that. 53 University of Ghana http://ugspace.ug.edu.gh • Outcome and Feedback: Data will be analysed and conclusions drawn from it will be made available to the municipal directorate. • Feedback to participant: Findings will be made available to the municipal directorate for records • Funding information: This study is self-funded • Sharing of participants Information/Data: The data is for the principal investigator • Provision of Information and Consent for participants A copy of the Information sheet will be given to you after it has been signed or thumb- printed to keep. Ethical approval This study will be reviewed and approved by the Ghana Health Service Ethics Review Committee. The committee is there to make sure that you are protected from harm and your rights are respected during participation in this study. Who to Contact for Further Clarification/Questions: Name: John Baptist Amissah Department: Health Policy Planning and Management, University of Ghana, Legon Mobile Number: 0277002858 Email:jamissah14@gmail.com 54 University of Ghana http://ugspace.ug.edu.gh Your rights as a Participant If you have any questions about your rights as a research participant, you can contact the Administrator of the GHS Ethics Review Committee at the following address: Hannah Frimpong GHS-Ethics Review Committee Research and Development Division, Ghana Health Service P.O. Box MB 190 Accra Office Number: 0302 681 109 55 University of Ghana http://ugspace.ug.edu.gh APPENDIX 2 CONSENT FORM FOR QUESTIONNAIRES Study Title: ECONOMIC BURDEN OF DOMESTIC VIOLENCE IN THE LEDZOKUKU AND KROWOR DISTRICTS OF THE GREATER ACCRA REGION, GHANA PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in a language I understand (English , Ga Twi ). I fully understand the contents and any potential implications as well as my right to change my mind (ie withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant………………………….. ID Code …………………………….. Participants’ Signature ………OR Thumb Print………… OR Mark (Please specify)…………. Date:…………………………………. INTERPRETERS’ STATEMENT (where applicable) I interpreted the purpose and contents of the Participants’ Information Sheet to the afore named participant to the best of my ability in the (Ga Twi ) language to his proper understanding. All questions, appropriate clarifications sort by the participant and answers were also duly interpreted to his/her satisfaction. Name of Interpreter…………………………… Signature of Interpreter……………………….. Date:……………………… Contact Details 56 University of Ghana http://ugspace.ug.edu.gh STATEMENT OF WITNESS I was present when the purpose and contents of the Participant Information Sheet was read and explained satisfactorily to the participant in the language he/she understood (English , Ga Twi ) I confirm that he/she was given the opportunity to ask questions/seek clarifications and same were duly answered to his/her satisfaction before voluntarily agreeing to be part of the research. Name:………………………… Signature……………. OR Thumb Print ……….... OR Mark (please specify)……………….. Date:…………………………… INVESTIGATOR STATEMENT AND SIGNATURE I certify that the participant has been given ample time to read and learn about the study. All questions and clarifications raised by the participant have been addressed. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 57 University of Ghana http://ugspace.ug.edu.gh APPENDIX 3 QUESTIONNAIRE ECONOMIC BURDEN OF DOMESTIC VIOLENCE IN THE LEDZOKUKU AND KROWOR DISTRICTS OF THE GREATER ACCRA REGION, GHANA. Dear Respondent, This is a research carried out on ECONOMIC BURDEN OF DOMESTIC VIOLENCE IN THE LEDZOKUKU AND KROWOR DISTRICTS OF THE GREATER ACCRA REGION, GHANA. I will therefore like to take some minutes of your precious time to answer these questions. You are assured that the answers you give will be strictly confidential and your name will not be mentioned in our research reports. Thank you. Qn. No. Questions Response Respondent ID: Section 1 SOCIO-DEMOGRAPHIC INFORMATION 1. What is your age in years? 2. What is the highest level of school you attended? 1. No education 2. Primary 3. Middle/JSS/JHS 4. SSS/SHS/Secondary/Vocational/Technical 5. Tertiary 3. What is your current marital status? 1. Single 2. Married 3. Co-habiting 4. Divorced 58 University of Ghana http://ugspace.ug.edu.gh 4. How many children do you have? 1. 1 to 3 2. 4 to 6 3. 6 or above 5. What is your employment status? 1. Employed 2. Unemployed 3. Student / Apprentice 4. Housewife 5. Retiree 6. If unemployed,why are you not working now? 1. Unable to work due to illness 2. Others (please specify)…………………………….. 7. If Unemployed, have you been looking for a job in the last 6 months? 1. Yes 2. No 8. If employed, in which sector are you employed? 1. Formal sector 2. Informal sector 9. What kind of job do you actually do? 1.Professional 2.Civil Worker 3.Artisan 4.Self employed 10. If Employed, what is your average monthly income? (i.e. salary plus other monies from other sources) GHS………………. 11. Are you an NHIS beneficiary? 1. Yes 2. No 59 University of Ghana http://ugspace.ug.edu.gh Section 2 DIRECT COST INFORMATION 1 When did you sustain this injury? 1. 1- 3mths 2.4 -6 mths 3.>6 mths 2 Is this your first injury of this same kind? 1.Yes 2. No 3 If No to Q2, how many times have you been injured? 1. 2 times 2.3 times 3.4 times 4.>5times 4 Have you sought medical care since your injury or last injury? 1.Yes 2. No 5 Where did you seek health care? 1. Primary 2.Secondary 3.Tertiary 6 Did you pay for the health care you sought? 1.Yes 2.No 60 University of Ghana http://ugspace.ug.edu.gh 7 Medical cost: how much have you spent during your hospital visit or stay in the management of the injuries GHC you sustained? 1. a. Surgical Intervention (s) if applicable 2. b. Registration 3. c. Consultation 4. d. Laboratory investigations 5. e. Medicines/drugs 6. f. Other diagnostic tests (such as scan etc.) 7. g. Any allied procedures such as dietherapy, physiotherapy 8. h. Other, specify: 9. Non-medical cost: how much did you spend/pay for (you and accompanying relative)? 10. a. Estimate of total travel cost (to and from the facility) 11. b. Food cost 12. c. Drinks/water cost 13. d. Other miscellaneous costs (i.e., phone calls/phone credits, other consumables used due to this illness) 14. e. Others, kindly specify: 15. Did you rely on financial help from other source (s) for treatment apart from normal income? 1. Yes 2. No 16. What are the sources (multiple responses possible)? 1. Relative 2. Friend 3. Savings 4. Loan/Grant 61 University of Ghana http://ugspace.ug.edu.gh 5. Other (Specify) 17. How much money did you receive from the identified source (s)? GHC……………… Section 3 INDIRECT COST INFORMATION 1. How many days in total have you absented from work (If applicable) because of the injury sustained? ……………..days 2. How many hours in total do you estimate to have spent traveling to and from the health facility and the police ………………hours station, aside the days lost (If applicable)? ………………days 3. How many minutes did you spend waiting before you were called to see the doctor or health officer for ……………….hours treatment aside the days lost (If applicable)? ………………..days 4. Did anyone from your household accompany you from home to the health facility/police station? 1. Yes 2. No 5. If anyone did accompany you to the health facility, what is his or her employment status? 1. Employed 2. Unemployed 3. Student 4. Housewife 5. Retired 6. Other, specify……………………..… 62 University of Ghana http://ugspace.ug.edu.gh 6. Did the person who accompanied you from the house take with you for the treatment and take you back home? 1. Yes 2. No If Yes in Q4 above, use same time as the patient’s in Q2 & Q3 for Q7 & Q8 7. How many hours/days in total did he/she travel to and fro to be with you in the health facility? …………………hours Or ……………days 8. How many hours/days in total did he/she spend with you when you were receiving treatment in the health facility? …………………hours Or ……………days 9. Total time spent at the health facility …………………hours Or ……………days 10. How many hours/days in total did he/she travel to and fro to be with you in the police station? …………………hours Or ……………days 11. How many hours/days in total did he/she spend with you when you were being taken through the legal processes? …………………hours Or ……………days 12. Total time spent for legal processes …………………hours Or ……………days Section 4 INTANGIBLE COST INFORMATION Please, select from the following statements concerning FEAR due to the injury sustained, from “not at all” to “extremely” depending on how it applies to you. 63 University of Ghana http://ugspace.ug.edu.gh 1. I think about my health now more than before since I sustained the injury 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 2. Because of the injury sustained, my future is of concern to me 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 3. I am always worried about sustaining another injury 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 4. When I think about my future health, I feel some uneasiness 1. Not at all 2. A little 3. Moderately 4. Quite a bit 64 University of Ghana http://ugspace.ug.edu.gh 5. Extremely Now kindly select again, from the following statements concerning PAIN due to the injury sustained, from “not at all” to “extremely” depending on how it applies to you 5. I always feel burning pain around the site of the injury 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 6. I have lost the sense of temperature at the region of injury and am not able to differentiate between warm and cold 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 7. I feel a dull aching discomfort when the site of injury is injury is function 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely Now kindly select again, from the following statements concerning EMOTIONAL SUFFERING due to the injury sustained, from “not at all” to “extremely” depending on how it applies to you 65 University of Ghana http://ugspace.ug.edu.gh 8. I suffer emotionally because I constantly worry about my condition 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 9. I think I am a burden to others because of my illness 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 10. I am constantly worried about exhibiting the loss of function resulting from the injury down in public 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 66 University of Ghana http://ugspace.ug.edu.gh 11. I feel embarrassed in social situations 1. Not at all 2. A little 3. Moderately 4. Quite a bit 5. Extremely 67