An exploration of evaluation approaches for community based interventions for people living with HIV (PLHIV) with results applied to the ‘HOPE’ programme in Ghana

Background: The increase in the number of people living with HIV (PLHIV), especially in sub-Saharan Africa, is a major public health concern. To date, most attention has been paid to prevention strategies and clinical trials of therapy. In comparison, there have been very few studies of care and support programmes. The ‘HOPE’ programme is a major community-based care and support programme in Ghana. ‘HOPE’ provides nutritional support, skills training for employment, health education and psychological support for PLHIV and for those orphaned through AIDS. Therefore, it was seen by policy makers in the country as desirable that it should be evaluated. A PhD scholarship was funded and the researcher presenting this thesis was appointed. Broad Aims The overall aim was to carry out an evaluation of the ‘HOPE’ programme in Ghana in order to make wider recommendations for evaluation of community-based interventions (CBIs) in Ghana and Africa generally. The timing was less than ideal as many of the major decisions about the intervention had already been made and baseline data had been collected. Therefore, the preliminary aim was to explore a range of possible evaluation methods so that the most suitable approach could be selected. Thereafter, a range of more specific aims, objectives and research questions was identified. Methods: A ‘mixed methods’ approach was adopted. The first component was a desk-based analysis of the literature on the various evaluation approaches that might, at least in theory, be applied to an HIV/AIDS intervention like ‘HOPE’. From this, a decision was made to evaluate ‘HOPE’ in terms of structure, process and outcome. The second component operationalised this decision by reviewing HOPE’s working documents and conducting two pieces of field work: a quantitative and a qualitative study. The quantitative study was a structured questionnaire administered to 200 PLHIV on the ‘HOPE’ programme. The qualitative study consisted of 14 interviews with stakeholders directly involved in the programme implementation and 8 focus group discussions with the programme beneficiaries. Results: The desk-based analysis achieved three main outcomes. First, it set out in a systematic manner the different approaches to evaluation that could in theory have been applied to ‘HOPE’. It identified strengths and weaknesses and the perspectives behind each approach. Second, it set out and then summarised a detailed description of the ‘HOPE’ programme and the national context in which it operated. Third, it set the above within the context of global literature on HIV, community-based interventions and nutritional support programmes. The analysis of the quantitative data showed that beneficiaries were being provided with soy-fortified wheat and vegetable fortified oil at the time of the evaluation. On average, beneficiaries gained weight (Mean difference in weight was 2kg with 95% CI (1.1, 2.9), p-value < 0.001) and increased Body Mass Index (BMI) (Mean difference in BMI was 0.8units with 95% CI (0.4, 1.2), P-value < 0.001). Over a third of the beneficiaries (37.5%) was currently unemployed and only one in five of the beneficiaries had been trained in a skill that might have been useful to find employment: this, despite skills training for all being a programme goal. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of a positive outcome. Qualitative components demonstrated perceived successes and challenges. Beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. They further indicated that the food was nutritious and contributed to their weight gain. Support groups have been sustained and membership increased. Some indicated that food should be more varied and some mentioned selling food to earn money to pay for their medications. Most of the beneficiaries indicated they were unemployed having lost their jobs as a result of stigmatisation. Only a few benefited from skills training leading to employment because of inadequate budgeting. Some who had been trained could not use their newly acquired skills because of lack of capital to start a business. To compound these weaknesses, most reported that they preferred petty trading to the skills offered. The monthly education and the training workshops generated hope, and improved knowledge of HIV/AIDS, promoted drug adherence and helped to reduce stigmatisation. The training of the PLHIV as peer educators is an effective method for HIV education and counselling since PLHIV listen to their peers more than health workers. Respondees predicted dissolution of the support groups when the programme ends. This is because they were not adequately involved in the decision making. Beneficiaries identified participation and cooperation as key prerequisites for sustainability but they also identified important weaknesses in ‘HOPE’ with respect to these criteria. Discussion: Despite the challenges presented by the timing and context of this study, it has been possible to carry out an evaluation that provides important learning. A mixed methods approach was appropriate and is likely to be useful in many similar evaluations. Beneficial outcomes were identified but these cannot be attributed, without qualification, to the intervention. Nonetheless, the findings indicated that participants were highly satisfied with the food support and monthly education. They were dissatisfied with the numbers trained in new skills and in other aspects of the skills training components. Also, the sustainability of the food component when the funding stops was a concern. However, the educational component could be sustained because peer educators could continue at very low cost. Most importantly, community involvement, using locally available resources, inter-sectoral collaboration and harnessing the motivation of local people were seen as key but underutilised ingredients. So, the results of the evaluation are encouraging but not conclusive. Nonetheless, care for people living with HIV is such an important problem that the desirability of conducting a cluster randomised controlled trial among a large number of support groups to assess the programme effectiveness on health, nutrition and economic status should be seriously considered despite the practical and ethical challenges implicit in such a recommendation

Socio-demographic factors associated with medication adherence among People Living with HIV in the Kumasi Metropolis, Ghana

Background Medication adherence is important to the survival of People Living with HIV (PLHIV) globally. Although, HIV viral load is reduced by antiretroviral therapy (ART), the number of people on ART continues to rise in Ghana. In the Kumasi Metropolis, Ghana, we looked at the socio-demographic factors associated with medication adherence among PLHIV. Methods A quantitative study involving 420 PLHIV who sought healthcare at the Kumasi South Regional Hospital was conducted utilizing a cross-sectional study design. We employed a structured questionnaire to collect data on medication adherence using the eight-item Morisky Medication Adherence Scale (MMAS) and socio-demographic factors that influence medication adherence. The data were analysed using Stata 14.2. Frequencies and percentages were used to present the descriptive data. The association between socio-demographic factors and medication adherence among PLHIV was investigated using both univariate and multivariate analyses. Results More than half (53.10%) of PLHIV adhered to ART. Place of residence was significantly established to be influencing medication adherence among PLHIV. PLHIV who were residing in urban centers (aOR = 3.61; CI = 2.24-5.82) were more likely to adhere to medication as compared to those who resided in rural areas. Conclusion Slightly more than half of PLHIV took their medicines as prescribed. Government and Policymakers such as the Ghana AIDS Commission, Ministry of Health, and Ghana Health Service should incorporate socio-demographic factors such as place of residence while creating and executing medication adherence initiatives to evaluate HIV management regimen for PLHIV

“We are Seen but not Recognized”; Disability Stigma and Disabled People’s Exclusion from Community Activities: The Case of Disabled People in a Traditional Community in Ghana

Society has a way of categorising and assigning expectations to its members. There are also rules regarding the norms and processes of dealing with problems of daily life. If a rule is broken during interactions between individuals in society resulting in abnormal situation, it can be labelled as stigma. When people perceive individuals as possessing socially unacceptable attributes, they assign negative qualities to the person and results in devaluation of the individual. Data was collected from disabled people and their leaders in the Kumasi Metro who were registered with the Department of Social Welfare. A qualitative study was conducted in which Interview and Focus Group Discussions were employed to collect data from respondents.  Purposive sampling technique was adopted to select 35 respondents for the study. After each data collection activity the recorded audio tapes and field notes taken during the interview were translated into English and later word processed. Data editing and categorisation was done manually based on the research objective. The study found that disability is stigmatised as a result of the reaction of society towards individuals who have impairments, disabled people have been given names based on their disability, disabled people have also lost the opportunity to inherit family wealth and to be installed as chiefs, and are unable to represent their communities and families at social functions. It is recommended that there should be effective public education on disability and the scientific causes of the condition.  Keywords: Stigma, Community-exclusion, Ghana, Disability, Society, Culture and Labelin

Provider-Client Perception and Experiences on the National Health Insurance Scheme (NHIS) Medicines List in Both Public and Private Pharmacy in the Bantama Sub-Metro of Ashanti Region of Ghana

Background: Health insurance schemes are formed in both developed and developing countries as a result of the existing challenges in the health care financing system stemming from uneven social and economic distribution. This study was conducted to find out the perception and experience of providers and clients in both public and private facilities on NHIS medicines list. Methods: A quantitative descriptive study was conducted  through systematic random sampling to recruit 455 participants from both Nimo Pharmacy (Private facility) and Komfo Anokye Teaching Hospital (Public facility). Results: Majority of the clients were aware of NHIS medicines or generics medicines and branded medicines. However, most of them preferred NHIS medicines to branded medicines. The reasons provided for opting for NHI medicines were effective (p-value= 0.088) affordability (p-value= 0.001) availability (p-value= 0.001), safety (p-value=0.645) and less side effects (p-value=0.012). Again, factors that might influence providers’ prescription patterns of NHIS medicines list were; provider’s personal preference, clients’ preference, confidence in the generic company and advertisement by generic company.Conclusion: A database of all generic medicines should be created as well as their inventory level be maintained for every accredited NHIS facility by the Ministry of Health and National Health Insurance Authority. This will make information on NHIS medicines readily available and clients can easily be directed to another accredited facility by the provider to access NHIS medicines if they are not available at the visiting facility. Keywords: Health Insurance, medicines list, client-provider-perceptions, Branded and generic medicines

Prevalence of Hypertension and Obesity among Women in Reproductive Age in the Ashaiman Municipality in the Greater Accra Region of Ghana

Ghana like many other developing countries is faced with a double burden of infectious and chronic non-communicable diseases. It is increasingly being recognised that unhealthy behavioural patterns such as poor dietary habits, physical inactivity, smoking, and excessive alcohol consumption significantly contribute to the development of many chronic non-communicable diseases such as hypertension, obesity, stroke, type II diabetes and cardiovascular diseases. This study sought to determine the prevalence of hypertension and obesity among women in reproductive age (? 20 ? 45); describe the dietary habits of the women; and ascertain how this may contribute to hypertension and obesity among the respondents. A descriptive cross-sectional study using interviewer-administered questionnaires was carried out among 254 women in reproductive age in the Ashiaman municipality. Study participants were selected through systematic sampling. The weight (kg) of the participants was taken using Salter scale and the height was also measured in cm using a stadiometer. Both weight and height measurements were used to calculate participants’ body mass index (BMI) and blood pressure (BP) readings were performed using a sphygmomanometer. The results showed that the prevalence rate of hypertension and obesity among the respondents was 20.1% and 9.8% respectively. The daily dietary choices of respondents revealed that all the respondents (254) consumed carbohydrates/fats &amp; oils  food daily with  less than a third of the respondents (80) including vitamins and mineral rich food which are mainly fruits and vegetables into daily diet. The results also indicated that 20.5% women who consumed carbohydrates, fats &amp; oils daily were hypertensive whereas the rest (79.5%) were normotensive. Effective and targeted health education and behaviour change interventions directed towards this segment of the population should be developed and implemented urgently. Key Words: Hypertension, obesity, prevalence, dietary habi

Antibiotics Availability and Usage in Health Facilities: A Case of the Offinso-South Municipality of Ghana

The use of antibiotics has received increased public health attention in recent times because their irrational use could pose a global health problem. Since the introduction of antimicrobial agents, there has been an association between antibiotic use and the development of antimicrobial resistance. The emergence of antibiotic resistance is primarily due to excessive and often unnecessary use of antibiotics in humans. This study therefore sought to assess antibiotics availability and usage in a municipal area of Ghana. The study was retrospective and descriptive in nature. Folders of 300 patients were sampled from a municipal hospital and three health centres. Simple random sampling technique was used in the recruitment of patients’ folders. The study revealed a high antibiotics usage in the municipality. Overall, respiratory tract infections rated the highest so far as conditions for which antibiotics were prescribed were concerned. The penicillins which were the frequently prescribed antibiotics formed 50% of prescriptions for the treatment of gastroenteritis, which was in violation of the existing standard treatment guidelines to be adhered to by prescribers. Regular training and refresher courses could be organized for prescribers towards ensuring the adherence to the existing treatment guidelines. Key words: antibiotics, availability, usage, health facilitie

Exploring the effects of the withdrawal of the capitation policy on Cesarean rates in public hospitals in Ghana: an interrupted time series analysis

Context and objectives. In Ghana, CS rates have increased by 2% since 2014 even though the World Health Organization has called for the procedure only for medically justifiable cases. Provider payment &nbsp;mechanisms such as capitation have been used to moderate CS rates in some settings. We explored the effects of the withdrawal of the capitation policy on the Cesarean Surgery (CS) rate in public primary care hospitals together with vaginal delivery (VD) and antenatal care for women with 4+ visits (ANC4+) rates. Methods. An interrupted time-series analytical design was used to assess the effects of the withdrawal of capitation on selected variables from the secondary District Health Information Management System (DHIMS 2) of public hospitals between January 2015 and December 2019. Results: The results show that after the policy withdrawal, the trend and level of provision of CS and VD were not significantly altered. Significant declining trends of ANC4+ reversed with significant positive trends after the policy removal. Conclusion. We conclude that the withdrawal of the capitation policy may not have impacted the CS rate significantly in public hospitals. Enhanced capitation payment mechanisms and specific policies aimed at limiting CS are needed to curtail the rise in Ghana