Prevalence, perceptions and associated factors of health insurance enrollment among older persons in selected cash grant communities in Ghana: a cross-sectional mixed method.

BACKGROUND: Universal Health Coverage has been openly recognized in the United Nations health-related Sustainable Development Goals by 2030, though missing under the Millennium Development Goals. Ghana implemented the National Health Insurance Scheme programme in 2004 to improve financial access to healthcare for its citizens. This programme targeting low-income individuals and households includes an Exempt policy for older persons and indigents. Despite population ageing, evidence of the participation and perceptions of older persons in the scheme in cash grant communities is unknown. Hence, this paper examined the prevalence, perceptions and factors associated with health insurance enrollment among older persons in cash grant communities in Ghana. METHODS: Data were from a cross-sectional household survey of 400 older persons(60 + years) and eight FGDs between 2017 and 2018. For the survey, stratified and simple random sampling techniques were utilised in selecting participants. Purposive and stratified sampling techniques were employed in selecting the focus group discussion participants. Data analyses included descriptive, modified Poisson regression approach tested at a p-value of 0.05 and thematic analysis. Stata and Atlas-ti software were used in data management and analyses. RESULTS: The mean age was 73.7 years. 59.3% were females, 56.5% resided in rural communities, while 34.5% had no formal education. Two-thirds were into agriculture. Three-fourth had non-communicable diseases. Health insurance coverage was 60%, and mainly achieved as Exempt by age. Being a female [Adjusted Prevalence Ratio (APR) 1.29, 95%CI:1.00-1.67], having self-rated health status as bad [APR = 1.34, 95%CI:1.09-1.64] and hospital healthcare utilisation [APR = 1.49, 95%CI:1.28-1.75] were positively significantly associated with health insurance enrollment respectively. Occupation in Agriculture reduced insurance enrollment by 20.0%. Cited reasons for poor perceptions of the scheme included technological challenges and unsatisfactory services. CONCLUSION: Health insurance enrollment among older persons in cash grant communities is still not universal. Addressing identified challenges and integrating the views of older persons into the programme have positive implications for securing universal health coverage by 2030.

Health of urban Ghanaian women as identified by the Women's Health Study of Accra.

OBJECTIVE: The purpose of the Women's Health Study of Accra was to provide an assessment of the prevalence of communicable and non-communicable illnesses. METHOD: This was a prospective, community-based study that included an interview for medical illnesses, a comprehensive physical examination, and laboratory testing. A total of 1328 women were examined at Korle Bu Teaching Hospital, University of Ghana. RESULTS: Prevalent conditions included poor vision (66.8%), malaria (48.7%), pain (42.8%), poor dentition (41.6%), hypertension (40.2%), obesity (34.7%), arthritis (27.1%), chronic back pain (19.4%), abnormal rectal (16.0%) and pelvic examinations (12.7%), HIV in women age 24-29 (8.3%), and hypercholesterolemia (22.7%). Increasing age, lack of formal education, and low-income adversely affected health conditions. CONCLUSION: The high prevalence of preventable illnesses in this expanding urban population indicates that the health care services are obligated to develop and provide screening, preventive strategies and treatment for both general health and gynecologic health conditions.

Sexual and reproductive health in Accra, Ghana.

OBJECTIVE: To describe sexual and reproductive health among women in Accra and explore the burden of sexual and reproductive ill health among this urban population. DESIGN: Cross-sectional study. METHODS: We analysed data from the WHSA-II (n=2814), a cross-sectional household survey on women's health, and supplemental data from an in-depth survey (n=400), focus groups discussions (n=22) and in-depth interviews (n=20) conducted among a sub-sample of women which focused specifically on reproductive health issues. RESULTS: Modern contraceptive use was uncommon. More than one third of women reported ever using abstinence; condoms, injectables and the pill were the most commonly reported modern methods ever used. The total fertility rate among this sample of women was just 2.5 births. We found a considerable burden of sexual and reproductive ill health; one in ten women reported menstrual irregularities and almost one quarter of women reported symptoms of a Sexually Transmitted Infection (STI) or Reproductive Tract Infection (RTI) in the past 6 months. Focus group results and in-depth interviews reveal misperceptions about contraception side-effects and a lack of information. CONCLUSION: In urban Ghana, modern contraceptive use is low and a significant proportion of women experience reproductive ill health (defined here as menstrual irregularity or RTI, UTI, STI symptoms). Increased access to information, products and services about for preventive care and contraception could improve reproductive health. More research on healthy sexuality and the impact of reproductive ill health on sexual experience is needed.

Secular trends in menarcheal age among Ghanaian women in Accra.

The Women's Health Study of Accra is a population-based cross-sectional survey that was conducted between March and September 2003 to assess the burden of disease in women in Accra. In addition to data relating to general health and living conditions, data on age at first menstruation was collected during the survey. A retrospective cohort analysis of the reported age at menarche was conducted using data from 2,644 women aged between 18 and 100 years. The median age of first menstruation of the entire cohort was 15.5 years and the median age of first menstruation among those aged <20 was 14.5 years. There was a statistically significant difference in median age at menstruation among the different age and socioeconomic groups. Multiple linear regression showed a significant decline of 0.2 years per decade in the mean age at menarche among Ghanaian women.

Vulnerability to sexually transmitted disease: street children in Accra.

PIP: A street child is someone under age 18 years who spends a considerable amount of time living or working on the street. Street children may have either run away from the home without their parents' permission, been forced onto the streets by their parents, or be orphans. Data are presented on 1147 street children aged 8-19 years interviewed between May 13 and June 9, 1997, in four market areas of Accra. Respondents also participated in focus group discussions. They were of mean age 16.1 years with 75% aged 15-19 years and only 2% under age 10. 60% of the sample is male. The street children were from all regions of Ghana, although the highest proportion of 22.1% was from the Ashanti Region, 20.1% from the Northern Region, and 14.6% from the Eastern Region. Most respondents are sexually active and typically had their first sexual experience on the street and with prostitutes. Most have multiple sex partners, some engage in homosexual activity, and they rarely and inconsistently use condoms despite being aware of AIDS. The children were more ignorant of other sexually transmitted diseases (STDs) against which they tend to self-medicate. Some girls provide sex in exchange for money. Street children are therefore at high risk for contracting and transmitting HIV and other STDs. They are also exposed to physical and social elements which may adversely affect their health, have repeated illness and infections which receive inadequate treatment, and consume recreational drugs.^ieng

Health-seeking behaviour of persons with HIV/AIDS in Ghana.

Historically, diseases whose aetiology could not be readily explained have been given supernatural explanations among the various ethnic groups in Ghana. Now HIV infection, with no known cure and origin, has been given a supernatural explanation. Such an explanation of disease causation influences people's attitude to the disease and to infected persons, and influences the health-seeking behaviour of infected persons. Data from a study on the Social Dimensions of HIV/AIDS Infections in Ghana are used to examine the health-seeking behaviour of some persons with AIDS interviewed in 1992. The paper examines the health care outlets used by infected persons and the reasons for using those outlets. Some HIV-infected persons in Ghana felt that they had been bewitched and, therefore, used multiple health care outlets, either serially or simultaneously, hoping that one of them might provide a cure or relief as well as explain the source of the infection. This is in spite of the continuing educational campaign stating that the disease has no cure. Such attitudes towards the disease and health-seeking behaviour should be considered in the design of programs for infected persons.

Postpartum sexual abstinence in the era of AIDS in Ghana: prospects for change.

Postpartum sexual abstinence for females has been identified as one of the socio-cultural factors with the potential for creating conditions for the sexual spread of HIV in areas where it is practised. In general, women are expected to abstain from sex after childbirth in order to ensure the survival of the mother and child. Men are not similarly expected to abstain and that has been used to rationalize polygyny. With changes in socio-economic conditions making it more difficult now than before to maintain two or more wives, particularly in urban areas, some men will abstain like their wives for fear of HIV infection; but such men may press their wives to resume sex early. Some women, on the other hand, may give in to the demands of their husbands by reducing the prescribed duration of postpartum abstinence. If this happens without the use of effective modern contraception, fertility may be affected. Some may also enter short or long-term relationship outside marriage, hoping that they will be safe from sexually transmitted infection. Using data from the Ghana segment of the Social Dimensions of AIDS Infection Survey, the study examines the responses of women who reported postpartum sexual abstinence and that of their partners. Both men and women reported abstaining, but some women were aware that their partners did not abstain as they did. Some of the women knew the sexual partners of their partners. Mostly it was men who made the first move to resume sex. For any behavioural change to occur, attitudes towards socially-constructed practices such as postpartum sexual abstinence will need to be changed by intensive education of both men and women and also through community support.

PIP: AIDS has been reported from all parts of Ghana and as of mid-1995, 15,980 people had been officially diagnosed HIV-positive out of an estimated population of 16.5 million. While women are generally expected to abstain from sex for some period following childbirth in the health interest of both the mother and child, men are not expected to abstain. These expectations and corresponding behavior have been used to rationalize polygyny. Difficult socioeconomic conditions, however, make it hard for men to support two or more wives. Some men following the birth of a child will therefore abstain like their wives out of fear of HIV infection, albeit entreating their wives to resume sex early. Other men may enter short- or long-term extramarital relationships. Findings are presented from the Ghana segment of the Social Dimensions of AIDS Infection Survey conducted March-April 1992 which examined the responses of women who reported postpartum sexual abstinence and those of their partners. A nationally representative random sample of 1364 men and 1034 women aged 15 to over 60 years was interviewed; 60% of the men and 56% of the women were married. Both men and women reported abstaining, but some women knew that their partners did not abstain as they did. Some women knew their husbands' sex partners and men typically made the first move to resume sex. Attitudes toward postpartum sexual abstinence must be changed through education in order for any behavioral change to occur.

Livelihood and the risk of HIV/AIDS infection in Ghana: the case of female itinerant traders.

Itinerant trading is the second major economic activity for women who constitute an important chain in the distribution of goods in West Africa. Historically they have played important roles in the political economy of Ghana. With the outbreak of AIDS these women, some of whom move far away from home sometimes for days for even weeks, stand the risk of being infected with HIV through their activities. Using a combination of methods including a survey, focus-group discussions and conversations with key informants; we examine how the trade is organized, the characteristics of the traders, and the risk factors that are likely to predispose them to contracting the AIDS virus. Itinerant women traders appear highly vulnerable, as women and as highly mobile people. This state of affairs, occasioned by the extremely difficult conditions in which the women work, is exploited for the sexual gratification of the men with whom they come into contact. The attempt to reduce the spread of AIDs through education has to target itinerant women traders at the points of transaction.

Migration and AIDS.

PIP: A successful short-term solution to transmission of AIDS in Western Africa by migrants involves provision of accessible and acceptable basic health and social services to migrants at their destination. The aim is to establish a sense of security and community, which is a health requirement. When migrants are excluded from community life or victimized as carriers of HIV infections, they will be driven by basic survival needs and dysfunctional social organization, which results in the rapid spread of HIV. Closing borders and mass deportation may not be an option. The long-term solution is population policy, environmental protection, and economic development. The focus on mapping the spread of AIDS must shift to a consideration of the migrant social conditions that make them vulnerable to AIDS. The issue of migration and AIDS will be addressed at the First European Conference on Tropical Medicine in October 1995 in Hamburg, Germany. In Uganda, HIV seroprevalence rates ranged from 5.5% among the stable population to 12.4% among internal migrants moving between villages to 16.3% among migrants from other areas. A World Bank project is operating in Western Africa, which traces seasonal male migration from the Cameroon to Liberia, Senegal to Nigeria, and from the Sahel to the coast during dry seasons. National border rules may influence the routes but not the extent of migration. A major destination place is Cote d' Ivoire, which has 25% of total population comprised of migrants from other countries and one of the highest HIV prevalence rates in Western Africa. On plantations prostitutes are brought in. Each prostitute serves about 25 workers. The pattern of sexual mixing contributes to the high HIV rates. Female migration is smaller and usually concentrated in prostitution at place of destination. Illiteracy and poverty drive women migrants into the trade. Their frequent health problems are malaria, pelvic pain, menstrual irregularity, vaginal discharge, and genital sores. Drugs are bought on the streets or from friends and may be of questionable efficacy. Health services may be sought upon return to the home country.^ieng

African families and AIDS: context, reactions and potential interventions.

This paper reviews publications and research reports on how sub-Saharan African families have been affected by, and reacted to, the AIDS epidemic. The nature of the African family and its variation across the regions is shown to be basic to both an understanding of how the epidemic spread and of its impact. The volume of good social science research undertaken until now on the disease in Africa is shown to be extremely small relative to the need.