Predictors of HIV status disclosure among people living with HIV (PLHIV) in Ghana:the disclosure conundrum and its policy implications in resource limited settings

BackgroundGlobally, over 40 million lives have been claimed by HIV/AIDS. In Ghana, more than 350,000 people are living with HIV. Non-disclosure of HIV status is a major barrier to HIV/AIDS eradication; yet, little is known of the determinants of HIV status disclosure in resource limited settings in Africa like Ghana.ObjectiveDetermine the predictors of HIV status disclosure among people living with HIV (PLHIV) and stimulate policy discourse on support systems for self-disclosure in Africa.MethodsThis is a descriptive cross-sectional study among PLHIV (n = 181) in sub-Saharan Africa, specifically the Volta region of Ghana. Bivariate probit regression was run to determine factors associated with HIV status disclosure among PLHIV.ResultsHIV status self-disclosure was reported by 50% of the respondents; nearly 65% disclosed their status to non-family members and non-partners. Significant correlates of HIV status disclosure either to partners or non-partners were marital status, monthly income, type of occupation, and being divorced due to HIV status (p ConclusionsHIV status disclosure remains low in Ghana like many African countries. There is the need for a renewed policy debate on tailored guidelines for HIV status self-disclosure and targeted support systems for PLHIV to ameliorate their predicaments and promote eradication of the epidemic in Africa

Influence of depression and interpersonal support on adherence to antiretroviral therapy among people living with HIV

BackgroundPoor adherence and under-utilization of antiretroviral therapy (ART) services have been major setbacks to achieving 95-95-95 policy goals in Sub-Saharan Africa. Social support and mental health challenges may serve as barriers to accessing and adhering to ART but are under-studied in low-income countries. The purpose of this study was to examine the association of interpersonal support and depression scores with adherence to ART among persons living with HIV (PLWH) in the Volta region of Ghana.MethodsWe conducted a cross-sectional survey among 181 PLWH 18 years or older who receive care at an ART clinic between November 2021 and March 2022. The questionnaire included a 6-item simplified ART adherence scale, the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), and the 12-item Interpersonal Support Evaluation List-12 (ISEL-12). We first used a chi-squared or Fisher’s exact test to assess the association between these and additional demographic variables with ART adherence status. We then built a stepwise multivariable logistic regression model to explain ART adherence.ResultsART adherence was 34%. The threshold for depression was met by 23% of participants, but it was not significantly associated with adherence in multivariate analysis(p = 0.25). High social support was reported by 48.1%, and associated with adherence (p = 0.033, aOR = 3.45, 95% CI = 1.09–5.88). Other factors associated with adherence included in the multivariable model included not disclosing HIV status (p = 0.044, aOR = 2.17, 95% CI = 1.03–4.54) and not living in an urban area (p = 0.00037, aOR = 0.24, 95% CI = 0.11–0.52).ConclusionInterpersonal support, rural residence, and not disclosing HIV status were independent predictors of adherence to ART in the study area

A Cascade Model of Mentorship for Frontline Health Workers in Rural Health Facilities in Eastern Uganda: Processes, Achievements and Lessons

Background: There is increasing demand for trainers to shift from traditional didactic training to innovative approaches that are more results-oriented. Mentorship is one such approach that could bridge the clinical knowledge gap among health workers. Objectives: This paper describes the experiences of an attempt to improve health-worker performance in maternal and newborn health in three rural districts through a mentoring process using the cascade model. The paper further highlights achievements and lessons learnt during implementation of the cascade model. Methods: The cascade model started with initial training of health workers from three districts of Pallisa, Kibuku and Kamuli from where potential local mentors were selected for further training and mentorship by central mentors. These local mentors then went on to conduct mentorship visits supported by the external mentors. The mentorship process concentrated on partograph use, newborn resuscitation, prevention and management of Post-Partum Haemorrhage (PPH), including active management of third stage of labour, preeclampsia management and management of the sick newborn. Data for this paper was obtained from key informant interviews with district-level managers and local mentors. Results: Mentorship improved several aspects of health-care delivery, ranging from improved competencies and responsiveness to emergencies and health-worker professionalism. In addition, due to better district leadership for Maternal and Newborn Health (MNH), there were improved supplies/medicine availability, team work and innovative local problem-solving approaches. Health workers were ultimately empowered to perform better. Conclusions: The study demonstrated that it is possible to improve the competencies of frontline health workers through performance enhancement for MNH services using locally built capacity in clinical mentorship for Emergency Obstetric and Newborn Care (EmONC). The cascade mentoring process needed strong external mentorship support at the start to ensure improved capacity among local mentors to provide mentorship among local district staff

Who uses outpatient healthcare services under Ghana’s health protection scheme and why?

Background: The National Health Insurance Scheme (NHIS) was launched in Ghana in 2003 with the main objective of increasing utilisation to healthcare by making healthcare more affordable. Previous studies on the NHIS have repeatedly highlighted that cost of premiums is one of the major barriers for enrollment. However, despite introducing premium exemptions for pregnant women, older people, children and indigents, many Ghanaians are still not active members of the NHIS. In this paper we investigate why there is limited success of the NHIS in improving access to healthcare in Ghana and whether social exclusion could be one of the limiting barriers. The study explores this by looking at the Social, Political, Economic and Cultural (SPEC) dimensions of social exclusion. Methods: Using logistic regression, the study investigates the determinants of health service utilisation using SPEC variables including other variables. Data was collected from 4050 representative households in five districts in Ghana covering the 3 ecological zones (coastal, forest and savannah) in Ghana. Results: Among 16,200 individuals who responded to the survey, 54 % were insured. Out of the 1349 who sought health care, 64 % were insured and 65 % of them had basic education and 60 % were women. The results from the logistic regressions show health insurance status, education and gender to be the three main determinants of health care utilisation. Overall, a large proportion of the insured who reported ill, sought care from formal health care providers compared to those who had never insured in the scheme. Conclusion: The paper demonstrates that the NHIS presents a workable policy tool for increasing access to healthcare through an emphasis on social health protection. However, affordability is not the only barrier for access to health services. Geographical, social, cultural, informational, political, and other barriers also come into play

Efficiency of private and public primary health facilities accredited by the National Health Insurance Authority in Ghana

BACKGROUND: Despite improvements in a number of health outcome indicators partly due to the National Health Insurance Scheme (NHIS), Ghana is unlikely to attain all its health-related millennium development goals before the end of 2015. Inefficient use of available limited resources has been cited as a contributory factor for this predicament. This study sought to explore efficiency levels of NHIS-accredited private and public health facilities; ascertain factors that account for differences in efficiency and determine the association between quality care and efficiency levels. METHODS: The study is a cross-sectional survey of NHIS-accredited primary health facilities (n = 64) in two regions in southern Ghana. Data Envelopment Analysis was used to estimate technical efficiency of sampled health facilities while Tobit regression was employed to predict factors associated with efficiency levels. Spearman correlation test was performed to determine the association between quality care and efficiency. RESULTS: Overall, 20 out of the 64 health facilities (31 %) were optimally efficient relative to their peers. Out of the 20 efficient facilities, 10 (50 %) were Public/government owned facilities; 8 (40 %) were Private-for-profit facilities and 2 (10 %) were Private-not-for-profit/Mission facilities. Mission (Coef. = 52.1; p = 0.000) and Public (Coef. = 42.9; p = 0.002) facilities located in the Western region (predominantly rural) had higher odds of attaining the 100 % technical efficiency benchmark than those located in the Greater Accra region (largely urban). No significant association was found between technical efficiency scores of health facilities and many technical quality care proxies, except in overall quality score per the NHIS accreditation data (Coef. = −0.3158; p < 0.05) and SafeCare Essentials quality score on environmental safety for staff and patients (Coef. = −0.2764; p < 0.05) where the association was negative. CONCLUSIONS: The findings suggest some level of wastage of health resources in many healthcare facilities, especially those located in urban areas. The Ministry of Health and relevant stakeholders should undertake more effective need analysis to inform resource allocation, distribution and capacity building to promote efficient utilization of limited resources without compromising quality care standards

Assessing the impact of a motivational intervention to improve the working lives of maternity healthcare workers:a quantitative and qualitative evaluation of a feasibility study in Malawi

BACKGROUND: Globally too many mothers and babies die during childbirth; 98% of maternal deaths are avoidable. Skilled clinicians can reduce these deaths; however, there is a world-wide shortage of maternity healthcare workers. Malawi has enough to deliver 20% of its maternity care. A motivating work environment is important for healthcare worker retention. To inform a future trial, we aimed to assess the feasibility of implementing a motivational intervention (Appreciative Inquiry) to improve the working lives of maternity healthcare workers and patient satisfaction in Malawi. METHODS: Three government hospitals participated over 1 year. Its effectiveness was assessed through: a monthly longitudinal survey of working life using psychometrically validated instruments (basic psychological needs, job satisfaction and work-related quality of life); a before and after questionnaire of patient satisfaction using a patient satisfaction tool validated in low-income settings with a maximum score of 80; and a qualitative template analysis encompassing ethnographic data, semi-structured interviews and focus groups with staff. RESULTS: The intervention was attended by all 145 eligible staff, who also participated in the longitudinal study. The general trend was an increase in the scores for each scale except for the basic psychological needs score in one site. Only one site demonstrated strong evidence for the intervention working in the work-related quality of life scales. Pre-intervention, 162 postnatal women completed the questionnaire; post-intervention, 191 postnatal women participated. Patient satisfaction rose in all three sites; referral hospital 4.41 rise (95% CI 1.89 to 6.95), district hospital 10.22 (95% CI 7.38 to 13.07) and community hospital 13.02 (95% CI 10.48 to 15.57). The qualitative data revealed that staff felt happier, that their skills (especially communication) had improved, behaviour had changed and systems had developed. CONCLUSIONS: We have shown that it is possible to implement Appreciative Inquiry in government facilities in Malawi, which has the potential to change the way staff work and improve patient satisfaction. The mixed methods approach revealed important findings including the importance of staff relationships. We have identified clear implementation elements that will be important to measure in a future trial such as implementation fidelity and inter-personal relationship factors