Design and methodology of a mixed methods follow-up study to the 2014 Ghana Demographic and Health Survey.

BACKGROUND: The intended meaning behind responses to standard questions posed in large-scale health surveys are not always well understood. Systematic follow-up studies, particularly those which pose a few repeated questions followed by open-ended discussions, are well positioned to gauge stability and consistency of data and to shed light on the intended meaning behind survey responses. Such follow-up studies require extensive coordination and face challenges in protecting respondent confidentiality during the process of recontacting and reinterviewing participants. OBJECTIVES: We describe practical field strategies for undertaking a mixed methods follow-up study during a large-scale health survey. METHODS: The study was designed as a mixed methods follow-up study embedded within the 2014 Ghana Demographic and Health Survey (GDHS). The study was implemented in 13 clusters. Android tablets were used to import reference data from the parent survey and to administer the questionnaire, which asked a mixture of closed- and open-ended questions on reproductive intentions, decision-making, and family planning. RESULTS: Despite a number of obstacles related to recontacting respondents and concern about respondent fatigue, over 92 percent of the selected sub-sample were successfully recontacted and reinterviewed; all consented to audio recording. A confidential linkage between GDHS data, follow-up tablet data, and audio transcripts was successfully created for the purpose of analysis. CONCLUSIONS: We summarize the challenges in follow-up study design, including ethical considerations, sample size, auditing, filtering, successful use of tablets, and share lessons learned for future such follow-up surveys.

Peer Influences on Sexual Activity among Adolescents in Ghana.

Little is known about the influences of peers on the sexual activity of adolescents in sub-Saharan Africa. Better understanding of these issues could lead to more effective sexual and reproductive health interventions. Using two waves of survey data from 1,275 adolescents in two southeastern Ghanaian towns, we examine age, sex, and community differences in peer group characteristics. We also examine prospective associations between peer group characteristics and self-reported sexual initiation and multiple partnerships during a 20-month follow-up period. Sex differences in peer-context variables were small. Affiliation with antisocial peers and perceived peer norms favoring sex increased the odds of transition to first sex. Having more friends increased the odds among younger respondents of acquiring multiple new sexual partners. Among males, perceived peer norms favoring sex increased the odds of acquiring multiple partners. We discuss the implications of these findings for adolescent sexual and reproductive health intervention strategies in sub-Saharan Africa, and conclude that peer-based interventions may be best suited to the needs of at-risk adolescent boys.

Reliability, Validity, and Associations with Sexual Behavior among Ghanaian Teenagers of Scales Measuring Four Dimensions Relationships with Parents and Other Adults.

Little research has been done on the social contexts of adolescent sexual behaviors in sub-Saharan Africa. As part of a longitudinal cohort study (N=1275) of teenage girls and boys in two Ghanaian towns, interviewers administered a 26 item questionnaire module intended to assess four dimensions of youth-adult relationships: monitoring conflict, emotional support, and financial support. Confirmatory factor and traditional psychometric analyses showed the four scales to be reliable. Known-groups comparisons provided evidence of their validity. All four scales had strong bivariate associations with self-reported sexual behavior (odds ratios = 1.66, 0.74, 0.47, and 0.60 for conflict, support, monitoring, and financial support). The instrument is practical for use in sub-Saharan African settings and produces measures that are reliable, valid, and predictive of sexual behavior in youth.

The impact of Ghana's R3M programme on the provision of safe abortions and postabortion care.

In 2006, in response to the high maternal mortality, driven largely by unsafe abortions, the government of Ghana, in partnership with other organizations, launched the reducing maternal mortality and morbidity (R3M) programme in seven districts in Greater Accra, Ashanti and Eastern, to improve comprehensive abortion care services. This article examines whether this intervention made a difference to the provision of safe abortion services and postabortion care (PAC). We also examine the role played by provider attitudes and knowledge of the abortion law, on providers with clinical training in service provision. Primary data on health care providers in Ghana, collected using a quasi-experimental design, were analysed using propensity score weighting. Apart from the treatment group, the sample included two controls: (1) Districts in Accra, Ashanti and Eastern, not exposed to the treatment; and (2) Districts from distant Brong Ahafo, also not exposed to the treatment. The findings show that providers in the treatment group are nearly 16 times as likely to provide safe abortions compared with their peers in Brong Ahafo, and ∼2.5 times as likely compared with providers in the other control group. R3M providers were also different from their peers in providing PAC. Associations between provider attitudes and knowledge of the law on both outcomes were either non-significant or inconsistent including for providers with clinical knowledge of abortion provision. Provider confidence however is strongly associated with service provision. We conclude that the R3M programme is helping safe abortion provision, with the differences being greater with control groups that are geographically distant, perhaps owing to lower contamination from movement of providers between facilities. Increasing provider confidence is key to improving both safe abortion provision and PAC.

Prevalence of anemia among under-5 children in the Ghanaian population: estimates from the Ghana demographic and health survey.

BACKGROUND: Anemia in children continues to be a major public health challenge in most developing countries, particularly in Africa. Anemia in the early stages of life leads to severe negative consequences on the cognitive as well as the growth and development of children, which may persist even after treatment. We examine the prevalence of anemia in under-five children in the Ghanaian population to help inform and serve as a guide to health policies and possible interventions. METHODS: Data from the 2008 Ghana Demographic and Health Survey (GDHS) was used. Data consists of health, demographic and socio-economic factors. Anemia status was determined using hemoglobin level, and prevalence of childhood anemia along with 95% confidence intervals was provided. We also examined the distribution of prevalence across different age and socio-demographic groups as well as the different regions and sub-regions in Ghana. RESULTS: The overall prevalence of anemia in under-five children in Ghana was 78.4% (N = 2168, 95% CI: 76.7-80.2), where 7.8% (N = 2168, 95% CI: 6.6-8.9) of the children had severe anemia, 48.0% (N = 2168, 95% CI: 45.9-50.2) moderate anemia and 22.6% (N = 2168, 95% CI: 20.8-24.4) had mild anemia. The highest prevalence regions were the Upper East, 88.9% (N = 158, 95% CI: 80.9-94.0), and Upper West 88.1% (N = 220, 95% CI: 76.4-94.6). The prevalence was also higher among children under 2 years of age, 85.1% (N = 781, 95% CI: 82.6-87.7) than children 2-5 years of age, 74.8% (N = 1387, 95% CI: 72.5-77.1). No significant difference in prevalence between boys and girls was observed. CONCLUSIONS: Given the high prevalence of childhood anemia observed in Ghana, particularly among those less than 2 years old, and given the negative consequences on their cognitive and behavioral development even in later years, there is an urgent need for effective and efficient public health interventions.

Adolescents and parents' perceptions of best time for sex and sexual communications from two communities in the Eastern and Volta Regions of Ghana: implications for HIV and AIDS education.

BACKGROUND: Adolescents and parents' differ in their perceptions regarding engaging in sexual activity and protecting themselves from pregnancy and sexually transmitted infections (STIs). The views of adolescents and parents from two south-eastern communities in Ghana regarding best time for sex and sexual communications were examined. METHODS: Focus Group interviews were conducted with parents and adolescents (both In-school and Out-of school) from two communities (Somanya and Adidome) in the Eastern and Volta regions of Ghana with epidemiological differentials in HIV infection. RESULTS: Findings showed parents and adolescents agree that the best timing for sexual activity amongst adolescents is determined by socioeconomic viability. In practice however, there were tensions between adolescents and parents crystallized by spoilt generation and physiological drive ideologies. Whilst one community relied on a more communal approach in controlling their children; the other relied on a confrontational approach. Sex-talk is examined as a measure to reduce these tensions, and children in both communities were ambivalent over sexual communication between their parents and themselves. Parents from the two communities however differed in their perceptions. Whilst parents in one community attributed reduced teenage pregnancies to sex education, those in the other community indicated a generalized adolescents' sexual activeness manifested in the perceived widespread delinquency in the community. CONCLUSION: Parents in both communities reported significant barriers to parents-adolescents sexual communication. Parents in both communities should be educated to discuss the broader issues on sexuality that affects adolescents and their reproductive health needs.

Psychosocial processes and sexual initiation among Ghanaian youth.

This study models primary abstinence and age at first sex in a cross-sectional sample of Ghanaian youth aged 17 to 22 years. The aim is to examine how reproductive knowledge and social cognitive factors jointly affect the choice to initiate sex. Among males, the authors find that reproductive knowledge is negatively associated with abstinence. Its negative association, however, is moderated by the extent of adult support a respondent receives. Among females, reproductive knowledge is positively associated with abstinence. Its positive association is moderated by the extent of household sex communication. Correspondingly, when age at first sex is modeled, knowledge is a negative predictor among females. Its effects are mediated by household sex communication. A third social cognitive variable, perceived permissive peer attitudes about sex, is not associated with knowledge but is a protective factor for sexual initiation for both sexes. Though causal direction cannot be established, the results suggest that cognition affects sexual initiation both directly and through complex social mechanisms. The evidence provides theoretical support for comprehensive adolescent sexual and reproductive health interventions that promote abstinence and other safe sex behaviors through social as well as individual pathways.

Clinic-based surveillance of adverse pregnancy outcomes to identify induced abortions in Accra, Ghana.

Reliable measures of induced abortion remain elusive, especially when the public perception is that the procedure is immoral or improper. This study draws on interviews using a modified preceding birth technique (PBT) with women attending antenatal and maternity clinics in Accra to compare rates of adverse pregnancy outcomes (stillbirths, miscarriages, and induced abortions) with rates from a household maternity history and the Ghana Demographic and Health Survey. The reports from the antenatal clinics produced some of the highest rates for adverse outcomes of pregnancy. In light of the generally high coverage of antenatal services found even in developing countries, the method based on the PBT holds promise for the improvement of reports of miscarriage and abortion worldwide.