Dodowa health research centre is one of the health research centers of the Ghana Health Service. The centre was set up as part of an agreement with ODA to have Operations Research satellite stations in the early 1990’s and has been involved in a lot of studies since then. It has had a close link with the District Health Administration for several years now.

Since its establishment in 1990 until May, 2004, the then District Director of Health Services acted as the head of the centre until June, 2004 when a head was appointed for the first time to run the Centre.

Most of the studies conducted at the centre have focused on developing and evaluating community and district based health interventions, obtaining information to improve the process of health policy, planning, and service delivery in the Ghana Health Service. This report focuses on activities carried out between June 2004 and the whole of 2005.

The aim of the centre is to conduct and disseminate research, build capacity in the conduct of research in specific areas of interest to the centre, be a training/resource centre for the use of social science techniques and tools and also be a member of the INDEPTH Network.

During the period under review, the centre continued with its research work focusing on malaria which is a number one problem in the district and also conducting research on family planning and HIV AIDS.

The centre managed to organise training courses in health social sciences for implementation research for both local and international participants at the end of 2004 and 2005 respectively. A baseline was conducted in the district for the setting up of a demographic surveillance system in the district and based on the completion of the work we were admitted formally into the prestigious INDEPTH Network.

The centre started off with the head, an accountant, a research officer, four research assistants and a driver and currently has staff strength of 20 with only two employed by the Ghana Health service. We are currently housed in four rooms, have no telephone or internet access. It is hoped that in the coming year we will make strides in ensuring that some of these challenges are addressed.

The Dodowa Health Research Centre was set up as part of an agreement with the then British Oversees Development Agency (ODA) now DFID to have Operations Research satellite stations in the early 1990’s. The studies focused on developing and evaluating community and district based health interventions and obtaining information to improve the process of health policy, planning, and service delivery in the Ghana Health Service.

At the time, the Head of the Research and Health Management Team was vested in one person and as a result, staff whose primary work is health administration conducted research as part of their work but after some time a core staff solely for research was put together and the two groups worked closely together. This was critical to the success of the type of research conducted in the centre.

Due to the growing nature of centre, the two functions (Head of Research and Head of health administration) were separated in May 2004 but very close links are still maintained with the District Health Management Team.

The Centre is one of the three health research centres of the Ghana Health Service tasked with the responsibility of conducting research within the health sector. It is sited as the name may suggest in Dodowa, the district capital of the District of the Greater Accra Region.

The district is rural but is gradually catching up with the rapid urbanization of the peripheral areas surrounding the city of Accra. It has the largest land surface area [about 1,700 square km] in the region and is bounded on the North by the Akuapim Ranges; to the South by Tema; to the East by River Volta and the West by Ga District. The land is flat and at sea level with isolated hills.

Among the hills are the ancient ’SHAI HILLS’ which is presently a Tourist attraction. The vegetation is mainly coastal savannah however, Dodowa boasts of a forest, which is popularly known as ’Dodowa Forest’.

The district is divided into four administrative sub districts, which are:

Dodowa [Shai] sub district, Prampram sub district, Great Ningo sub district (Formerly Old Ningo) And Osudoku sub district. The Osudoku and Old Ningo sub districts cover a greater land area than the Prampram and Dodowa sub districts.

At the same time, they have the worst roads in the district. Apart from Akuse road leading into Asutsuare town, and the old Asutsuare road, none of the roads in the Osudoku sub districts is tarred.

Even the tarred roads are not in very good condition. In the rainy seasons, some of the villages are inaccessible except with a four-wheel drive. At the same time, the scattered nature of the population means that a lot of effort is needed to reach a few people.

The population is however not dense, with an estimated population of 120,065 and a 2005 estimated population growth rate of 4.4%. Baseline information gathered for the setting up of a demographic

surveillance system in the district indicates that the population of the district is 98, 681. Details of the population will be presented in the section on DSS.

Most of population lives in scattered small communities of less than 2000 people. It is completely rural with wide spread poverty - subsistence farmers, fishermen and petty traders and a handful of artisans and civil servants. The district is deprived and therefore has most people migrating out to find jobs always seemed to have a projected population, which was more than the actual. When the 2000 census was carried out, this was found to be so.

However, the new projection of 4.4% applied to the whole of Greater Accra Region again puts the district at a disadvantage. To this end, the research centre has plans of putting a demographic surveillance system in place to have an accurate population base and to keep track of the people in the district.

Each district has a health institution with either one or two community clinics. In total, there are six community clinics, two in dodowa, one in prampram, two in Osudoku and one in Ningo, which also serves as a Community Health and Planning Services (CHPS). There is another CHPS centra at New Ningo, which is within the Prampram sub district. There are four private institutions in the district that send monthly returns to the District Health Administration. These institutions are Ebenezer Clinic, Grace Maternity Home, Afienya Community Based Clinic and St Andrews Catholic Clinic.

Most of population lives in scattered small communities less than 2000 people. There is wide spread poverty - subsistence farming, fishing and petty trading are the main occupation of the people and a handful of them are artisans and civil servants.

Institutional Relationships

Dodowa Health Research Centre is one of the three health research centres of the Ghana Health Service. It responds technically to the Health Research Unit which is one of the four units of the Policy planning Monitoring and Evaluation Division (PPMED) of the Ghana Health Service and administratively to the Greater Accra Regional Health Directorate.

The Centre through its activities and functions contributes to the overall objectives of the Division, which are

1. To ensure the development of comprehensive policies, sustainable strategic plans, systems, programs and budget to cover the activities of the Ghana Health Service and its partners
2. Develop an integrated Health Information system for decision-making performance monitoring.
3. To design and apply monitoring and evaluation systems and tools for purposes of assessing the operational effectiveness of programmes.
4. To initiate or support the development of new products based on credible research for the advancement of the objectives of the Ghana Health Service.
   
   

The centre has close working relationships with the Dangme West District Health Administration; the Dangme West District Assembly, the Navrongo and Kintampo Health Research Centre. Students Pursuing the Masters in Public Health Program (MPH) at the school of Public Health in the University of Ghana come to the district for their field attachment and spend time in the research centre seeking technical support.

The centre collaborates with other institutions like:

INDEPTH Network

1. INDEPTH Network
   Partnership for Social Science in Malaria Control;
2. London School of Hygiene and Tropical Medicine;
3. Erasmus University in Amsterdam; WHO/TDR;

Objectives of the Centre

1. To take part in identifying and carrying out priority operational/health systems / applied research to help address policy, planning and implementation needs of the GHS.
2. To build multi-disciplinary capacity in the relevant disciplines within the research centre to provide technical support for research in the GHS.
3. To build capacity in finding effective solutions and implementation alternatives to identified need and problems.
4. To disseminate results of research findings to key people, policy makers and anyone responsible for health care in a meaningful way.
5. To have a functioning DSS and be part of the INDEPTH Network
6. To be a resource centre for training in Health Social Sciences for implementation research

GENERAL ADMINISTRATION

Human Resource

Before May 2004 when a substantive head was appointed, the staff of the District Health Administration and other staff of the Ghana health service carried out research activities. In 2004, the centre had a staff of 10. At the end of 2005 the staff strength had increased to 19 as follows:

• Phd;
• Degree social scientists;
• Accountant;
• HND Statistics;
• Data Manager;
• Data assistant;
• Data entry clerks;
• Drivers;
• Cleaner;

Transport/Estate

The Centre is housed in a four-room apartment on the Premises of the Shai Osudoku District Health Administration. It used to be the former office of the District Health Directorate. The four rooms

serve as Field Office, Data Entry, Accounts Office and office of the director. The Center has recently acquired land for setting up a permanent structure for the Research centre.

The centre has the following means of transport:

• Toyota Land Cruiser;
• Mitsubishi Pick up;
• Motorbikes;
• 15 Bicycles;
  
  

For routine activities however motorbikes and bicycles and sometime vehicles are borrowed from the District Health Directorate.

Stores and Supplies

The centre accesses its items from the DHMT Stores under the supervision of the DHMT storekeeper.

Financial Resources and its Managements

The main source of funding of the Centre is from research projects. The director and the accountant are the only staff on the Government of Ghana pay roll however it contributes towards the administrative cost of the centre. Plans are underway to ensure that as many of the staff are absorbed into the Ghana Health Service as much as possible.

The studies conducted in the centre have received funding from:

• World Health Organisation (WHO/TDK/);
• Ghana Dutch Collaboration for Health Research;
• Ghana Health Service;
• Gates Malaria Partnership;

Standard financial management procedures of the Ghana Health Service are observed and the appropriate auditors within the district assembly and the Ghana Health Service do auditing

Research/Training Activities

Deployment of Rectal Artesunate in the Shai Osudoku District for severe Malaria in Children Under Five:

Margaret Gyapong, Sheila Addei, Evelyn Ansah, John Gyapong, Irene Agyepong

Background

All over the world, mortality from malaria seems to be on the increase with over 1-2 million deaths each year. Over 90% of these are African children who due to poor access to health facilities and local perceptions about the disease reach health facilities too late to survive severe complications of malaria.

As a result, the WHO has directed the development of a new drug likely to offer considerable survival benefit for patients who presently die from lack of immediate access to appropriate treatment. The anti-malarial in question is a rectal formulation of artesunate, which achieves rapid and substantial (99-100%) reduction of parasitaemia within 24 hours of administration. It permits emergency treatment of patients who cannot take drugs by mouth and who do not have immediate access to injectable treatment.

Objectives

1. To determine community definition and treatment seeking for severe malaria
2. To design and implement a multimedia educational strategy at community and health facility level
3. To document the proportion of febrile NPO children who received RA and sought subsequent care
4. To document the course of action for febrile NPO children who received RA but did not seek care at HF

Methodology

An observational study carried out in two phases was designed. A formative phase to understand perceptions regarding severe malaria and the course of action at both health facility and community level and an intervention phase which included intensive IEC followed by the deployment of the drug at all possible sources (traditional and orthodox) in the district. Communities were randomized into three arms (Mother Coordinator, Community Directed and Routine Health Service).

The formative phase and Intervention activities have been completed. Since August 2005 the rectal formulation has been deployed for use in the district to date, 392 severe malaria cases have been recruited. The results will focus on the formative phase and intervention activities.

Results

Local terms used to describe malaria Community members perceive that there are two types of "Asra" (term for malaria) the "Eyoo" Female type which is mild and characterised by headache, fever, hot body, loss of appetite, bitterness in the mouth. The "Eku" which is the male Type is more serious and can Kill. It is characterised by inability to eat or drink, convulsions, change in mental status, anaemia, lump or sore in stomach.

The survey conducted showed a similar trend but majority felt that malaria was malaria with no distinction. In naming the different types, apart from mentioning the Eyoo (11.6%) and eku (11.7%), fever (24.9%) and jaundice (7.6%) were also mentioned as types of malaria.

Even though majority of respondents mentioned mosquito as the cause of malaria the perception about the sun and other factors that cause malaria, which came out during the formative phase, was also mentioned, caretakers however recognized signs of severe malaria as follows Very hot body (54%), Severe vomiting (23%), Loss of appetite (18%), and Anemia (14%). These are all treated in a wide range of ways that include sponging, giving of drugs bought from a chemical shop, going to a traditional healer and going to the health facility.

As is the practice in most places, the first point of call in ill health is the home and care is sought there as soon as the illness begins. The traditional healer and the chemical shop follow this. The drug peddler would usually be visited the day after the illness begins followed by the clinic, which is commonly visited three days after the onset of ill health.

The commonest conditions reported at health facilities ate fever, chills, vomiting, pallor and convulsions in that order however, the condition of greatest concern is the convulsion and it is no wonder that it is a condition that care takers will rush to a health facility with.

Rectal use of Drugs

The use of herbal and other preparations rectally for treating various signs and symptoms of Asraku is common. The combinations of pepper, ginger, soap and other preparations in the enema is however a source of concern.

Decision making in health care seeking

There was the need to find out the primary decision maker in health care seeking for children. This was necessary in order to target the education of community members to caretakers and these decision makers to ensure that children showing signs of severe malaria would receive the appropriate kind of care.

The main decision maker and advisor on health care seeking is the father of the sick child. The mothers and grandparents also have a say in seeking care for the sick child. Other relatives and friends seem not to play a role in taking decisions for health care seeking.

Generally 57 % of caretakers who were interviewed indicated that that they did not need permission to send their children for health care seeking but even if they did it was the father who gave the permission to do so and this is done mainly when the finances for the health care has to come from some place other than the home.

Geographic Access

In seeking care, 53% of respondents walked, 26% took a taxi and another 19% used a mini bus popularly known as TroTro Use of motorbike and bicycle were not common ways of accessing care and only 0.5% and 1.0% of respondents indicated they used a motorbike and bicycle respectively. About 48% of all caretakers who walked to access health care indicated it took them between 5-10 minutes.

Another 39% indicated it took between 10-30 minutes to seek health care when walking. For those who had to take a taxi in the event that the condition got a little more serious, it took about 10-30 minutes to seek care and the same amount of time if the care taker used a mini bus (trotro).

Bearing in mind that estimation of time and distance may be a problem, a further question (regarding ease of accessing) care was asked to cross check the information given with regard to geographic access to health care. Respondents were asked how difficult it is to access health care.

Generally, whilst 18.5% of respondents felt it was easy to access care, 53% indicated it was difficult and another 26% mentioned it was very difficult to access care. The main reasons were money (90%), transportation (15%).

Communicating Health Information

As part of putting the intervention in place, there would be the need to embark on a health education campaign. For this to effectively take place, the research team needed to know the sources of health information in the district. The survey results indicate that the three main sources of health Information in the study district as mentioned by caretakers are the Health worker (90%) the drug peddler (12%) and the Chemical Shop.

Other surveys in the district asking about source of general information in the district had shown that the Radio was a popular source. This survey asked specifically about health information and interpersonal communication and talks supplemented with the information van seemed to be the main source of health information with the talks being the most appealing.

Intervention processes

• The study team went through a number of processes to put the intervention in place:
• Dissemination of formative phase results to the DHMT and all sub district health staff and planning for the intervention;
• Randomisation of communities in the district into three arms;
• COM the approach where community members decide on who and how to administer the drug;
• MUM the approach where groups of mothers with one coordinator are in charge of the drugs and ensures that children have direct access to it
• MOH using the existing health system

All these were done bearing in mind distance to the nearest health facility and selecting communities with more than 100 children under 5. A total of 93 were randomised.

Designing and finalization of health education materials and messages

Flip charts, posters and treatment charts were prepared. In addition community durbars supplemented with testimonies from mothers, talks supplemented with announcements from an information van were held all in the bid to educate community members on the drug. This was done based on information from the formative phase.

• Training of health workers as trainers of the drug distributors identified at community level
• Deployment of the drug

Key Findings

To date, the RA has been deployed in 70 communities and 9 Health Facilities in three sub districts. The work has been done with a total of 140 Drug Distributors and five field supervisors. As shown in figure 11, a total of 392 children under five have been recruited with majority of them from the COM arm.

In the MOH arm not all the communities had a heath facility as a result; the health workers had to appoint community health workers to handle the drugs in some of the MOH communities. The actual recruitment at heath facility therefore is 26 making 7% of the total recruitments.

Most of the children were recruited in the 12-36 month group and the main signs they presented with are inability to eat or suck, severe weakness and repeated vomiting.

Over 90% of the children recruited received the correct dose for their age and were referred to the nearest health facility. About 80% of all those who were referred complied and of those who did not, 33% went to other places like chemical shops or to a traditional healer instead of going to the health facility. Another 28% did not go anywhere because they felt their children had recovered.

Conclusions

We think that the community based distributors can administer the rectal formulation. The fact that over 80% of the distributors are able to comply with the referrals within 24 hours and the distributors can follow up on the children and check on the status is encouraging. With the use of the Rectalartesunate, there is the potential of reducing the number of referred cases from the Health Centre level to the hospital because of the initial treatment at the community level.

THE DEMOGRAPHIC SURVEILLANCE SYSTEM

Introduction

As part of work in the district, the first census was conducted in the early 1990’s with national service personnel and health staff. This was done in only one of the 4 sub-districts because the study was focused in that area. In the year 2000 prior to setting up of the district wide health insurance scheme the census was re done.

This time Assembly men. National service personnel were used to collect the data whilst DHMT members supervised the work. The aim was to generate community registers for the HI scheme. This activity was however wrought with a number of problems.

1. The House numbering and enumeration was not done in a uniform order for easy identification.

2. The registers printed were inaccurate due to problems with the computer program used.

3. Some communities and houses were not covered.

4. Several new communities had sprung up since the last census in the early 1990’s

5. The information could not be updated due to lack of Funds Technical Capacity

However, with the growing nature of the centre, there was the need to write good proposals and attract good partners to the centre. Having a population base and being able to detect and account for population changes, monitor health problems in the district and gather information that will contribute to policy decisions, would be a useful way of doing that and hence the need to have a proper demographic surveillance system in place. Dodowa DSS data collection and processing

The baseline data collection started in February 2005 and ended in October 2005. Data was collected at household level with 12 field workers and 2 field supervisors. The information collected was basically name, age, sex, occupation, education, religion, ethnicity and relation to head of household. The team plans to conduct its first round of data collection in January 2006 and update bi-annually (Births, Deaths, Pregnancies, Migration,).

Information on Education, ITN use, iodated salt use, IPT intake. Insurance registration status and Immunization status will be updated annually. As part of the baseline data collection, houses were numbered according to the scheme

This is the way the houses had been numbered in previous attempts at census in the district. The electoral area codes are however posing a problem since they change over time. All electoral area codes are therefore going to be replaced with area council codes (there are 7 fixed area councils in the district). With help from the Navrongo Health Research Centre, the database was corrected to take care of these changes.

Data management

All forms were printed from the computer centre using the old census information as a basis. The forms were logged out according to communities in each of the sub districts. The completed forms are checked in the field by a supervisor before they are brought into the filing office and then entered by a data entry clerk. Any discrepancies are returned to the field an resolved before it is brought back to the computer centre for entry. The information gathered has been fed into the annual report of the district and will be presented at the annual review conference of the Regional health administration.

Demographic Indicators

The 2005 population of the district was estimated to be 120,000 however the DSS baseline information indicates a population of 98,165 with 22,981 households, 13,496 houses all in 381 communities and 7 Area councils. The main occupation is farming or fishing and 38% of the population have never been to school. They are a predominantly Christian population (88%) and are

mainly of the Dangme Ethnic group.

Mutual Health Organizations (MHO’S) in Ghana and Implications for improving the success of Health Insurance in Ghana. Edward Bruce, Solomon Narh-Bana, Irene Akua Agyepong, Rob Baltussen, Institute for Medical Technology Assessment (iMTA), Erasmus Medical Centre, Rotterdam, Grant Rhode, Simed International the Netherlands Mutual Health Insurance Schemes are becoming increasingly popular as a financing mechanism in sub-Saharan Africa. The last ten years has seen the number of Mutual Health Organizations (MHO) in Ghana grown dramatically. The growth of these organizations has been largely uncontrolled, indicating the desire of people to support each other in financing their health care cost.

Private schemes began emerging in Ghana in the mid 1990’s, and the government is currently establishing public schemes in all of its 138 health districts. Success will depend on first, the knowledge and capacity to manage these schemes, and secondly on building trust in the community to attract and keep clients.

A survey was conducted on 45 private and public schemes in Ghana in 2004-2005, to document their management performance, and relations with the community. Questions were structured according to three dimensions, i.e. structure, financial management, and financial position of schemes.

The main objective was to prepare an inventory of risk mechanisms and other technical features of mutual health schemes in Ghana and its effects on economic sustainability of the schemes.

Specifically the study wanted to:

• Prepare an inventory of risks mechanisms to control moral hazards and adverse Selection.
• Prepare an inventory of approaches to efficient service delivery.
• Measure economic sustainability and financial performance of some selected MHO’S in Ghana.
• Make specific recommendations for the effective regulation of MHO’S in Ghana.

Existing MHO’S were grouped according to Regions with the help of literature from some projects funded by DANIDA. Having done this, schemes that have been operating for more than one year were selected from all the regions for interviews.

Out of a total of 78 existing and emerging MHIS which were identified by consulting different sources (Aikins 2003, Danida 2003), 47 of them were functioning (i.e. were registering members), and were included in the survey. Two MHIS could not be reached because they had either collapsed or merged with the district wide Schemes.

Results

Initiation and ownership of schemes Of the 45 schemes interviewed 24.4% of them were community initiated, 17.8% of them had been initiated by religious groups, 17.8 % of were Ministry of Health initiated, 9% by the Ghana Health Service and the remaining by the district assembly or others.

In terms of ownership, 86.67% of them were owned by the members of the scheme 4.44% of them were owned by non-governmental authorities like churches, 6.6 % of them were owned by the Parent Teacher Association (PTA) and 2.2% of them were owned by the community.

Means of identification setting of premiums and services offered

In insurance, it is important that members of the scheme have a means of identification. In the survey, 93.3% of the schemes issue out membership card with Photo, whereas 4.4% of them have membership card without Photo.

Actuarial methods are scientific methods of calculating insurance risk and of the 45 Schemes surveyed 77.8% of them used actuarial method to set the Premiums and 82.2% of them used actuarial methods to define benefits covered in the Scheme. 57.8% of the schemes set the premiums in conjunction with the members of the scheme.

As at the time of the survey 77.8% of the Scheme Managers interviewed had received formal training related to the work they do. 86.6% of the schemes survey offer both in and outpatient services to their clients and

Risks Mechanisms to Control Moral Hazards

Moral hazard is the tendency of members of schemes to consume more health care than necessarily needed because they do not have to pay at the point of use. Some of the measures used to control moral hazards include; co-payment, maximum refundable sum for services and the use of a gatekeeper system for referrals.

In order to answer risks mechanisms to control moral hazards questions relating to co-payment, maximum refundable sum for services and referral letters were analyzed and the responses are recorded in table 1 below indicate that most of the schemes (84%) require referral letters as a means of verification for claims made on the hospital bills of patients.

Risks Mechanisms to Control Adverse Selection

Adverse selection is when the scheme attracts relatively sick people because they are more likely to benefit. In order to answer risks mechanisms to control adverse selection, questions relating to individual registration, waiting period.

Cherry Picking and community participation were analyzed and can be seen in table 2 below. Individual registration refers to allowing people to register as members of the scheme individually and not as a household or family and this has the potential of attracting only sick people to be members of the Scheme.

Waiting period refers to the Probation period ie the period after registration before members can benefit from the Scheme. This helps to prevent people from benefiting from the Scheme only in cases of emergency and thus controls adverse selection.

Cherry picking refers to a situation where only sick people or people with chronic illnesses are registered as members of the Scheme and this has the ability to collapse the scheme in the shortest possible time.

Community participation refers to the regular involvement of the community members in meetings where decisions are taken concerning the Scheme. It has the potential of controlling adverse selection since the community itself is involved in taking decisions to solve this problem of Adverse selection and they themselves will be ready to check members of the community who would like to benefit from the scheme illegally.

The success of any scheme depends to a large extent on the type of service delivery package negotiated with the service providers Table 3 indicates that almost all schemes had independent providers who used drugs from the essential drug list, did not include preventive services and had a formal contract with the provider.

The study concluded that private schemes have more autonomy in setting premiums and benefit packages and had higher community participation in meetings as compared to public schemes. Schemes had few measures in place to control moral hazard and reduce adverse selection but more so to control fraud and prevent cost escalation.

The vast majority of schemes were managed formally by trained and paid staff. The financial results of schemes varied considerably. It was also recognized that Ghanaian authorities would need to regulate schemes in their effort to establish public schemes on a nationwide scale. This may be useful to improve their financial management but schemes should retain enough autonomy to adapt to local situations and to expand business by building trust.

Assessment of male involvement In Family Planning decision making and practice and Its influence on the uptake of Family Planning in the Shai Osudoku District.

Family planning has become an issue of national concern because of pressure on the limited resources of the country. Though the proportion of Family Planning acceptors in the Shai Osudoku District continues to increase over the past years the achievement is still low (11.5% in 2001). Whilst very few men are involved in family planning in the district some women use the methods secretly because their male partners are unhappy about the practice.

There are some factors which may contribute to low involvement in FP but the extent to which these factors discourage male involvement in FP is not very clear in the district and hence the study which is aimed at assessing the problem and its contributing factors which will assist the study team in the design of strategies to enhance male participation in FP.

General Objective

To assess the extent and nature of male involvement in Family Planning (decision making and practices), and its influence on uptake and identify interventions to improve male involvement in increasing family planning uptake in District.

Specific Objectives

• To describe the level of knowledge among men on family planning and its influence on their involvement in family planning decision making and practices.
• To describe the use of family planning clinics and methods used by men.
• To describe the attitude of service providers towards men in family planning clinics and the attitude of males towards the service providers.
• To determine the level and type of influence men have on women in the choice and use of contraceptives.
• To describe the extent of support men give to women concerning family planning.
• To develop/design based on the study findings strategies that will improve male involvement and associated increased uptake of family planning in Shai Osudoku District.

Study Design

The study was a descriptive and cross-sectional one and was conducted at health facility and community level. Data collection methods include Focus Group Discussions, In-depth Interviews, Case Studies, Document Review and the use of a structured Questionnaire.

Results

For the survey, a total of 420 heads of household were interviewed with equal numbers of male and female heads of household as respondents. Their ages ranged between 18-95 years. Quite a number of the respondents had had some form of education (75%) the breakdown is as follow

Almost all the respondents (65%) were married but 26% have never been married before. The rest were either widowed (2.9%) or had never been married before (5.5%). Over 76% of the respondents had one partner and 19% had no partner. Few (3.5%) had more than 2 partners. The number of children that the respondents had ranged between 0-16 and they were engaged in a wide range of occupations with majority being fishermen or farmers as presented in Knowledge on Family Planning and influence on its use

Awareness of FP is high with about 92% of the respondents having ever heard about family planning. More females (52.2%) than men (47.8%) had heard of family Planning and the main source of information was the clinic, Hospital and the Chemical shops.

It appears from the chart that the most common family planning methods that the respondents know of are the condom.

Pill and injectable

These methods appear to be known by more women (50.5%) than men (49.5%). The focus group discussions indicated that the preferred methods are the condom, Norplant and pill. Other methods they mentioned included Abstinence and the use of the menstrual cycle as a guide.

Factors affecting FP Usage

Men and women in the study area had a wide range of perceptions about factors (both negative and positive) which affected family planning usage. Many more men than women were concerned about the fact that the use of family planning methods led to bareness and made the women unfaithful.

Women were more concerned about the fact that using family planning methods made them lose weight, made them more prone to heart disease and other conditions like dizziness, swellings of the leg, prolonged menstrual flow, irregular menses and the like.

Perception on factors affecting usage of Family Planning Methods

Some religious people believe that children are a gift from God and it is wrong for one to decide against the will of God. A respondent said "we should not practice family planning if we realty know God", another said "because of the teachings of the Bible that we should produce but family planning is against it".

Perception on Manhood

To understand factors that affect male involvement in family planning, it was necessary to understand community definitions on manhood and who a man is. In the focus group discussion with women, the perception was that a man is anyone who has a lot of male children, one who has been able to make a woman pregnant, one who is "good" in bed and one who can take care of a family.

The men were of the opinion that a real man is one who has been circumcised, has a lot of money, has a wife many children and can take care of them.

The Husband factor

Many husbands do not permit their wives to practice family planning because of the perception of promiscuity. This is because there is the perception that pregnancy could expose them if they engage in any extramarital affairs. Therefore allowing one to practice family planning gives one the freedom to indulge in extramarital affairs.

Some wives have lost their marriages because they were practicing family planning without the knowledge of their husbands. Three of such cases were found during the period of the study. Below is an extract from one of them.

Gloria who is 40 years old has 7 children. She practiced family planning using Norplant for one and half years without his knowledge till he realized it. According to her, "he was annoyed and sacked me from the house". Gloria has lost her marriage because she concealed her family planning status from her husband because her husband wanted her to have more children. Her husband could not trust her anymore.

Opinion about women practicing Family Planning

Decision making and role of spouses in Family Planning Information on this was gathered from focus group discussions held with men and women. In the women’s group, the consensus was that the women don’t have a say the men always decide.

"These men, they never agree if we want to practice family planning so what is the point in telling them we will rather do it in secret". The men were generally upset that the women practice family planning in secret. For them it is not just an issue of the women practicing it to protect themselves from having children but the perception that the women do it to enable them be promiscuous. They don’t think women have a say in deciding on family planning. One man said

Opinion on male involvement

There was an agreement that men are not very much involved in family planning issue and a number of issues to that effect were raised.

Insufficient male methods

• Due to the side effects that some women encounter, there should be more male methods available;
• There are only 2 methods for men. Condom and Vasectomy;
• One woman indicated that the condom is good but she is very unsure about the vasectomy.
• Male health staff should also be involved in family planning education and counseling.

Family planning is seen as a women’s’ affair and is one of the reasons why men hardly visit the health centre with their wives.

What compounds this perception is the fact that most of the methods are targeted at women. A male respondent said "Following the women to the clinic is a problem how much more because of family planning"

• Men in general and male health staff in particular should take the lead in championing the cause of male involvement in family planning.
• Various social groups are unaware of the importance of male involvement in family planning and activities should be organized for them so that they can also advise others.

Summary and conclusions

The study revealed that men are not generally involved in family planning and this is as a result of a number of factors which include their perception on manhood and the role of women in family planning decision making. The women do not seem to have a say and must abide by the rules of the spouse.

On the other had the reasons why men do not want their women to practice family planning (promiscuity etc) are unfounded and need to be addressed through intensive health education. Some health sector factors also contribute to the low involvement of men in family planning. They include the kind of staff who talk about family planning and the availability of only 2 methods for men one of which is easily available on the market.

Moreover, visiting the health centre is a woman’s thing and must not be ventured into by men. The positive finding is that both men and women see the need to have men involved in family planning and gave suggestions as to how it can be done giving the impression that male involvement in family planning is possible and necessary however the challenges that go with it would need to be taken care of.

Introduction

Stigma related to HIV/AIDS is the greatest barrier to preventing further infections and provision of adequate care support and treatment and in the alleviating of impact. In Ghana, there is little documentation on the nature and extent of HIV related stigma.

The aim of the study was to describe the nature and extent of HIV/AIDS and its effect on PWLHA and the families affected by the disease in order to adopt appropriate interventions to reduce stigma related HIV/AIDs in the district.

Objectives

The main objective of the study was to describe the nature and the extent of stigma related to HIV/AIDS in the Shai Osudoku District.

Specific Objectives

The specific objectives were:

1. To find out how community members perceive HIV/AIDS illness and their perception about the diseases in relation to other sexually transmitted diseases and chronic diseases
2. To determine the attitude and behaviour of individual community members and families of PLWHA towards PLWHA
3. To find out how people living HIV/AIDS perceive themselves and their opinions about the disease.
4. To find out what individuals community members, families and PLWHA could do to reduce HIV/AIDS related stigma.
5. To use study findings as a guide to plan appropriate HIV/AIDS intervention programs that involve persons living with HIV and those affected by HIV/AIDS to reduce HIV/AIDS related stigma in the Shai Osudoku District and other districts in Ghana.

This exploratory study used both qualitative and quantitative data collection techniques. Respondents included adult males and females, and involved the use of focus group discussions, indepth interviews and a structured questionnaire.

Results

Community Perception about HIV/AIDS in relations to STI and Chronic diseases The study has demonstrated that community members have a wide range of perceptions and opinions about HIV/AIDS. Majority believed that HIV/AIDS is a deadly and a fearful disease.

They also believe that HIV/AIDS is shameful and a disease with no cures which affects people of promiscuous lifestyles and the disobedient. There were still others, though not the majority who also believed that HIV/AIDS is a spiritual and a white man disease.

HIV/AIDS was considered a more stigmatized disease than other Sexually Transmitted Infections such as gonorrhea and syphilis. It was also regarded as more stigmatizing than some chronic diseases such as TB, mental illness, leprosy and cancer that have been known to the communities.

However, there were few community members who consider people who are mentally ill or families that are affected by mental illness to be more likely to be stigmatized than people and families living with HIV/AIDS. It is therefore important to say that stigma is not only unique to HIV/AIDS. It has been documented with other infectious diseases like tuberculosis, syphilis, and leprosy (Herek 1998; Goldin 1994).

There was also a belief and perception among community members and more especially among males that women are the group of people who mostly get HIV/AIDS. The impact of HIV/AIDS on women is particularly acute in many developing countries. In a number of societies, women are mistakenly perceived as the main transmitters of sexually transmitted diseases.

Together with traditional beliefs about sex, blood and the transmission of other diseases, these beliefs provide a basis for additional stigma of women within the context of HIV/AIDS In some African countries for example, women whose husbands have died from AIDS-related infections, have even been blamed

for their death (Fredricksson, J and Kanabus, A 2004).

Ghanaian women have been identified as a group with increased vulnerability to infection with the HIV virus (Disease Control Unit, 1996) and this vulnerability might be influenced by factors such as gender, unequal power relationships and poverty (Mills J.E and Anarfi J.K, 2001).

Attitudes and Behavior of Individuals and Families of PLWHAs towards PLWHAs Stigma related to HIV/AIDS was recognized to exist in communities in the study area because community members displayed some stigmatizing responses towards HIV/AIDS disease and people living with HIV or AIDS.

The feelings by some individual community members that the negative attitudes and behaviour towards PLWHAs could not be reduced was an evidence that stigma related to HIV/AIDS still exist within communities. These attitudes are prevalent because community members still believe that PLHWAs are individuals who have once lived a promiscuous lifestyle and as a consequence have got what they deserve. Studies show that stigma is often associated with a disease whose cause is perceived to be the bearer’s responsibility (Herek G.H et. al 2002, Appiah E.N, 2000).

To the extent that an illness is perceived as having been contracted through voluntary and avoidable behaviour, especially if such behaviour evokes disapproval, is likely to be stigmatized and evoke anger and moralism rather than pity or empathy (Weiner, 1993).

Thus, because the primary transmission routes for HIV (sexual intercourse and sharing of infected needles) are widely perceived to be voluntary and immoral behaviours, people with HIV are regarded by many people as responsible for their condition and consequently are stigmatized (Herek G.H, 1999).

The study also revealed that fear associated with HIV/AIDS make people reject and shun PLWHAs. Throughout the focus group discussions community members expressed fear about the disease, which to most of them prevents people from reaching out to people living with HIV/AIDS and eating with them or even allowing them to prepare meals for them.

The fear related to HIV/AIDS make people believed that people affected with the disease might deliberately or mistakenly get others infected with the virus. A study which was conducted in the United States on public reaction to AIDS, for example, also provided evidence that people have fear toward PLWHAs (Herek G.H, 1992).

It is therefore important to understand that fear is one of the manifestations of HIV/AIDS stigma in many part of the world including Ghana. Thus, educational intervention to eliminate or reduce fear associated with the disease is required if HIV/AIDS stigma is to be reduced.

The study was also able to show that community members did not like a person living with HIV/AIDS to continue working in their organization. This finding clearly confirmed an earlier study conducted in the district which revealed that people suspected or known to have AIDS were been sacked from their jobs (Survey Report: ICD, 2000). AIDS -related discrimination in employment has been widely reported since the early days of the epidemic.

PLWHAs have been fired from their jobs (Gostein, 1989, 1990) and some employers have also used pre-employment screening where means of testing is available and especially in industries where health benefit is available to employees to deny employment to people living with HIV and AIDS (Fredricksson, J and Kanabus, A 2004).

Again the study was able to find out that unmarried people who are diagnosed of HIV has limited chance to get into marriage given the fact that no community member desire to marry a person living or suspected to have HIV because of the burden that goes with the disease. Gyapong M et al (1996) in a study on Filariasis and some cultural belief and practice in the Northern Ghana reported that unmarried people have a problem of getting married when they have filariasis.

Similarly, a study on Stigma associated with Onchocercal Skin Disease (OSD) in Western Nigeria for instance also reported that OSD is also associated with social stigma including problems finding a marriage partner (Brieger W R et al., 1998). Like Filariasis and Onchocercal skin disease, people who get HIV/AIDS are shunned and become isolated within their communities.

For these people, the chance of finding a spouse are slim, and since they are often unable to work, they become dependent for care and financial support, leading to insecurity, shame, and isolation. Community members also felt that person living with HIV and AIDS are regarded less inferior and they are likely to receive less care than people with other chronic diseases. All these imply that there is some form of stigma associated with AIDS disease and persons suspected to be living with HIV in the district.

In many African countries, families are the primary care givers to sick members. There is clear evidence of the importance of the role that the family plays in providing support and care for people living with HIV and AIDS (Fredrikson J, Kanabus A, 2004.)

However, not all family members’ responses are positive. The widespread of AIDS-related morbidity and mortality, however, are threatening the integrity and viability of African families in many AIDS affected areas.

Additionally, the stigma associated with AIDS often isolate families in units as they try to cope with an AGDS- affected family member (Preble E A, Foumbi J., 1991). In this study for example, the extended family of PLWHA continues to display stigmatizing attitudes towards family member who have HIV/AIDS because of their perception that they have brought disgrace and shame to the family.

Moreover, most of these families are caught up in poverty such that the struggle for survival and lack of adequate income for support and care make them shun and deny these victims. However, there were also increasingly evidence that immediate family are gradually becoming comfortable living with family members living with HIV/AIDS and this might be as result of continuous communication and education messages they hear on HIV/AIDS.

Community members also expressed high level of willingness to meet PLWHAs and even their willingness to go to the extent of shaking hands with them. There were others who claimed that they were willing to visit and offer some sort of care to a friend and also a family member living with the disease.

Over 50% of individual community members in the survey also felt that they would be comfortable telling friends about a family member who is living with the HIV or AIDS and they also thought effect on the disease on chances of other family members in with regards to marriage is very little.

This information attests to the fact that some community members have some sort of positive attitudes and behaviour towards people living with HIV or AIDS, That is, it is not always the case that peoples’ attitudes and behaviour towards PLWHAs is negative.

Attitude and Perceptions of PLWHA

Information obtained in the study also demonstrate that PLWHAs perceive greater stigma towards themselves than how other community members perceive the disease and think about PLWHAs. It was noticed that these individuals live in greater fear and worry. Their perception about HIV/AIDS as a shameful and a graceful disease and the fact that people living with HIV/AIDS would eventually become lean before they die leave them in continuous fear, worry and discomfort.

These perceptionsare also manifested in self-pity, self- loathing, self-blame, thoughts of dying early or suicides and isolation (Herek GM, Klitzman, 1997). The fear of denial, rejection, abuse and isolation were what they expressed as preventing them from disclosing their HIV/AIDS status to other individuals. A previous study in Ghana on breaking the news of HIV infection indicated that the secrecy surrounding breaking the news of HIV infection is one signs of AIDS stigma (Mill J.E, 2003).

Thus, encouraging disclosure within a trusting and supportive environment may be one of the strategies to diffuse AIDS stigma in the study area. Desire for marriage especially among PLWHAs who were singles was something they lack because they believe it is better to live alone than to enter marriage to complicate their present ill health. Community Members attitude themselves when considered as PLWHA

About 50% of Individual community members interviewed also were not ready to disclose their HIV/AIDS status if they happen to have HIV infection. They felt disclosure of ones HIV/AIDS status could lead rejection and discrimination. They believed that they might feel uncomfortable telling others and also the discomfort it might bring to other family relation.

For those who felt that could they disclose their HIV and AIDS status, majority talked about disclosing it to their mothers. This was followed by friends and children, and then followed by fathers, sisters and brothers. The rest were pastors and other family members. It is important to note that the aggregate of the immediate family members formed the majority.

This was followed by friends. Members of the extended family were the least mentioned. It is therefore clear that any attempt for intervention for people living with HIV or AIDS in the district should considerably involve immediate family members to achieve positive outcome.

Potential way to reduce HIV/AIDS related Stigma

The study was able to show that education and communication are the potentials means to reduce stigma related to HIV/AIDS. Even though some opinions were that HIV/AIDS related stigma could never be reduced or a reduction in stigma related to HIV/AIDS is thing of the future, many still believe that when PLWHA are made to feel wanted, encouraged and also are shown love these negative feelings would be reduced.

They felt as part of education people should receive continues messages that HIV and AIDS is similar to any another disease and also efforts should be made by families to give them good food.

Education and communication messages on HIV/AIDS were also admitted by PLWHAs as one of the surest ways to reduce stigma associated with the disease. Other way that was recommended by

PLHWA was the introduction of drugs that could cure HIV/AIDS disease.

They also suggested together with community members and families that if they could be assisted financially to be engaged in some form of income-generating activities it could go a long way to reduce the negative thoughts and worries they have about themselves.

Maintaining strong religious ties was also recommended as a positive way to reduce the negative thoughts and perception person living with HIV and AIDS have towards themselves.

Research Capability Strengthening In Health Social Science for Implementation Research

Tropical diseases have a tremendous impact on developing countries, leading to inequity and escalation of poverty. Reducing mortality, morbidity and disability caused by tropical diseases is a key factor in the alleviation of inequity and poverty, and fostering social and economic development. In order to address these problems, a lot of focus is being placed on Implementation research.

The overall objective of implementation research is to significantly improve access to efficacious interventions against tropical diseases by developing practical solutions to common critical problems in the implementation of these interventions. This move into Implementation Research requires certain intellectual concepts, skills, capacities and partnerships that are outside the biomedical domain.

Health Status

Health Administration

For administrative purposes and to facilitate health services delivery, the district has been sub-divided into four Health sub-districts, which coincide broadly with the traditional areas namely; Dodowa, Prampram, Great Ningo and Osudoku sub-districts.

Health Facilities

There are ten (10) static MOH health facilities

Mutual Health Insurance Scheme

DEVELOPMENT OF THE HEALTH INSURANCE SCHEME

Background Introduction

Baseline studies 1993

• UNICEF & MOH funding
• PhD study (Dr. Dyna Arhin) on feasibility and willingness of community to pay for health insurance in District
• Planning phase 1996 - 2000 (DHMT)
• Long planning phase in part because of need to carefully design but also in part because of some:
• Organizational turmoil (change in leadership at MOH - HQ)

Financing of the design and implementation

MOH was supposed to finance the intervention & EU the monitoring and evaluation. MOH funding did not materialize. EU provided only part of agreed funding.

Planning phase involved extensive dialogue and negotiation with:

• Community members
• District Assembly
• Providers

Purpose was to make sure scheme design was responsive to the needs of the community and the reality of the Ghanaian situation.

• It takes time to really talk and understand and design what will work in our context
• District assembly used part of UNDP poverty reduction funds to support the census of households
• A major repeated concern of the community was that cost of services was not the only or an absolute barrier to use.
• Quality of care specifically provider attitudes, drug availability, prompt and speedy recovery without complications etc all affected their decision as to whether they were willing and able to pay for health insurance.

Description of scheme

1. First insurance year 1st October 2000 - 30th September 2001 completed
2. 2nd insurance year (1st October 2001 - 30th September 2002) completed
3. 3rd insurance year (1st October 2002 – 31st December 2003).
4. Subsequent years have run from 1st January to 31st December (starting from fourth year)
5. Scheme is now in the 6th year of operation (Under National Health Insurance Act 650 and L.I. 1809 Regulations)

Registration and benefit

• Voluntary membership
• Household registration
• Individual photo ID
• Fixed annual registration period

Initial Benefit package

• Consisted of all primary care (OPD) services and referral care up to a maximum of ¢200,000.00 per referral episode for year 1 and 2
• Same benefit package for year 3 & 4, but referral ceiling rose to ¢400,000.00.
• Current benefit package (year 5) - the NHIS benefit package.

There is no ceiling as to what should be paid. The only condition is that, the diagnosis should be in the benefit package as stated in the L.I. 1809.

Premium

1. Mandatory household registration
2. Census of households carried out with the district assembly before the Scheme took off
3. Premium
4. 1st year 12,000/adult, 6,000/child under five and those over 70
5. 2nd & 3rd year 15,000/adult, 6,000/child under five and those over 70
6. 4th year 25,000/adult, 15,000/child under five and those over 70
7. 5th year using NHIS premium schedule: minimum ¢72,000.00 and registration fee of ¢10,000.00/head

Health Facilities

Rationalization of levels of care and use of a gatekeeper system (gate keeper) First level of Care is at any of the listed primary care facilities below.

• 10 Public sector primary care clinics in Shai Osudoku
• Private clinic (Ebenezer) in Prampram
• Private clinic in St. Andrews Clinic kordiabe (CHAG signed 2004)
• Private medical laboratory in Prampram and Ningo
• Adorn Medical Laboratory (Prampram)
• Godia Clinic (Dawhenya) signed on in 2006.
• Omari Clinic Mataheko (Afienya road) signed on 2005. All private.

Referral Facilities

1. No hospitals in the district
2. Referral hospitals all outside the district have been negotiated with to provide referral care
3. In the initial years of operation these have been 5 namely
4. Tema General Hospital
5. Akuse Government Hospital
6. Battor Catholic Hospital
7. St. Martins Hospital, Agomanya
8. Atua Government Hospital (Somanya) currently looking at Ridge Hospital for year 6

Enrollment Trends

• 774 households containing 3,063 individuals were registered for 2000/2001
• 1692 households containing 6,017 individuals were registered for 2001/2002 insurance year
• 2103 households containing 8108 individuals were registered for 2002/2003 insurance year
• 3031 households containing 12372 individuals were registered for 2004
• 3141 households containing 13523 individuals have been registered for 2005 benefit year