Stigma, discrimination, violence, and HIV testing among men who have sex with men in four major cities in Ghana.

LGBTQ populations experience human rights abuses worldwide; data need to document the health impact of these experiences in Africa. In Ghana, we measured events of sexuality-based stigma, discrimination, and violence among men who have sex with men (MSM) and the impact on HIV testing behavior. Data are from respondent-driven sampling surveillance surveys in Accra/Tema, Kumasi, Cape Coast/Takoradi, and Koforidua. Discrimination was common among MSM: 6.2%-30.6% were refused services, 29.0%-48.9% experienced verbal/symbolic violence, 2.8%-12.8% experienced physical violence, 12.3%-30.0% experienced sexual violence due to their sexuality in the preceding year. MSM who experienced sexual violence in their first male sexual encounter were less likely to ever test for HIV in Accra/Tema and Cape Coast/Takoradi. Further studies are needed to examine the impact of stigma and violence on MSM's HIV health-seeking behavior in Ghana. Structural interventions are needed to mitigate the consequences of stigma and discrimination on MSM health and well-being.

Predictors of primary and secondary sexual abstinence among never-married youth in urban poor Accra, Ghana.

BACKGROUND: Sexual abstinence is a key component of the strategy to address unwanted pregnancies, sexually transmitted infections and HIV among youth in sub-Sahara Africa. But contextual pressures make abstaining from sex a formidable task for urban poor youth in the sub-region. Nevertheless, some youth in these settings still manage to resist the pressure to initiate sex early, while others choose abstinence after an initial sexual debut. Few studies in the sub-region have examined sexual abstinence among urban poor youth. We therefore examined the factors that predict primary and secondary sexual abstinence among youth in urban poor Accra. The findings highlight the protective factors associated with sexual intercourse and should help to address the needs of youth at risk of unprotected sex. METHODS: The study analysed pooled data from two rounds of the Urban Health and Poverty Survey. The surveys analysed were conducted in 2011 and 2013. The analysis was restricted to unmarried youth between age 20 and 24 years. The total sample comprised 235 female and male youth. We conducted multinomial logistic regression analysis to examine the predictors of primary and secondary abstinence relative to current sexual intercourse. RESULTS: The results showed that being female, sexual communication with only fathers, sexual communication with only friends and slum residence were negatively associated with primary sexual abstinence. Contrarily, being in school, attaching importance to religion, residing in a household that received social support and sexual communication with both parents were positively associated with primary abstinence. Regarding secondary abstinence, only the sexual communication variables had significant effects. Sexual communication with both parents positively predicted secondary abstinence while communication with fathers-only and friends-only had a negative effect. CONCLUSION: Sexual abstinence is predicted by factors which range from individual through household factors to the locality of residence. Despite the importance of all the predictors, the study found that sexual communication with both parents was the only factor that predicted a higher likelihood of both primary and secondary sexual abstinence. We therefore recommend sexual communication between parents and youth as a key strategy for promoting sexual abstinence among urban poor youth in Accra, Ghana.

Sense of community and willingness to support malaria intervention programme in urban poor Accra, Ghana.

BACKGROUND: The extensive research on community members' willingness to support malaria interventions ignores the role of psychosocial determinants. This study assesses the impact of individuals' sense of community (perceptions of community cohesion, altruism, seeking help from neighbours and migrant status) on their willingness to participate in a mosquito control programme using data on 768 individuals from the 2013 RIPS Urban Health and Poverty Survey in poor coastal communities in Accra, Ghana. A contingent valuation experiment was employed to elicit individuals' willingness to support the programme by contributing nothing, labour time/money only or both. RESULTS: Findings show that different dimensions of sense of community related differently with willingness to support the programme. Perceived community cohesion was associated with lower odds while help-seeking from neighbours and being a migrant were associated with higher odds of supporting the programme. Altruism was the only dimension not linked to willingness to participate. CONCLUSIONS: Different dimensions of sense of community are associated with community members' willingness to provide labour, time or both to support the malaria eradication programme. The findings of this study have implications for targeting social relational aspects, in addition to geographical aspects, of communities with malaria-resilient policy and intervention. They also warrant further research on psychosocial factors that predict willingness to support health programmes in urban poor settings.

What are the characteristics of 'sexually ready' adolescents? Exploring the sexual readiness of youth in urban poor Accra.

BACKGROUND: Adolescent sexual activity, especially among the urban poor, remains a challenge. Despite numerous interventions and programs to address the negative consequences arising from early and frequent sexual activity among youth in sub-Saharan Africa, including Ghana, only slight progress has been made. A plausible explanation is that our understanding of what adolescents think about sex and about their own sexuality is poor. In that sense, examining how adolescents in urban poor communities think about their sexual readiness, and identifying characteristics associated with that sexual self-concept dimension, should deepen our understanding of this topical issue. METHODS: A total of 196 male and female adolescents, ages 12 to 19, were surveyed in the 2011 RIPS Urban Health and Poverty Project in Accra, Ghana. The youth responded to three statements which determined their levels of sexual readiness. Other background characteristics were also obtained enabling the assessment of the correlates of their preparedness to engage in sex. The data were analyzed using ordered logistic regression models. RESULTS: Overall, the majority of respondents did not consider themselves ready for sex. Multivariate analyses indicated that sexual experience, exposure to pornographic movies, gender, ethnicity and household wealth were significantly linked to their readiness for sex. CONCLUSION: Sexual readiness is related to sexual activity as well as other characteristics of the adolescents, suggesting the need to consider these factors in the design of programs and interventions to curb early sex. The subject of sexual readiness has to be investigated further to ensure adolescents do not identify with any negative effects of this sexual self-view.

Migration, sexual networks, and HIV in Agbogbloshie, Ghana.

BACKGROUND: HIV is spread through structured sexual networks, which are influenced by migration patterns, but network-oriented studies of mobility and HIV risk behavior have been limited. OBJECTIVE: We present a comprehensive description and initial results from our Migration & HIV in Ghana (MHG) study in Agbogbloshie, an urban slum area within Accra, Ghana. METHODS: The MHG study was a population-based cross-sectional study of adults aged 18-49 in Agbogbloshie in 2012. We used a one-year retrospective relationship history calendar to collect egocentric network data on sexual partners as well as migration and short-term mobility, and tested for prevalent HIV-1/2 infection. RESULTS: HIV prevalence was 5.5%, with prevalence among women (7.2%) over twice that of men (2.8%). Three-quarters of residents were born outside the Greater Accra region, but had lived in Agbogbloshie an average of 10.7 years. Only 7% had moved housing structures within the past year. However, short-term mobility was common. Residents had an average of 7.3 overnight trips in the last year, with women reporting more travel than men. Thirty-seven percent of men and 9% of women reported more than one sexual partner in the last year. CONCLUSIONS: Population-based surveys of migration and sexual risk behavior using relationship history calendars in low-resource settings can produce high quality data. Residents in Agbogbloshie are disproportionately affected by HIV, and have high levels of short-term mobility. HIV prevention interventions targeted to highly mobile populations in high prevalence settings may have far-reaching and long-term implications.

Psychosocial stressors among Ghanaians in rural and urban Ghana and Ghanaian migrants in Europe.

Psychosocial stressors have significant health and socio-economic impacts on individuals. We examined the prevalence and correlates of psychosocial stressors among non-migrant and migrant Ghanaians as there is limited research in these populations. The study was cross-sectional and quantitative in design. A majority of the study participants had experienced stress, discrimination and negative life events. Increased age, female sex, strong social support and high sense of mastery were associated with lower odds of experiencing psychosocial stressors in both populations. Interventions should be multi-level in design, focusing on the correlates which significantly influence the experience of psychosocial stressors.

Household food sources and diarrhoea incidence in poor urban communities, Accra Ghana.

Diarrhoeal diseases remain a significant cause of morbidity and mortality, particularly in poor urban communities in the Global South. Studies on food access and safety have however not considered the sources of discrete food categories and their propensity to harbour and transmit diarrhoeal disease pathogens in poor urban settings. We sought to contribute to knowledge on urban food environment and enteric infections by interrogating the sources and categories of common foods and their tendency to transmit diarrhoea in low-income communities in Accra. We modelled the likelihood of diarrhoea transmission through specific food categories sourced from home or out of home after controlling for alternate transmission pathways and barriers. We used structured interviews where households that participated in the study were selected through a multi-stage systematic sampling approach. We utilized data on 506 households from 3 low-income settlements in Accra. These settlements have socio-economic characteristics mimicking typical low-income communities in the Global South. The results showed that the incidence of diarrhoea in a household is explained by type and source of food, source of drinking water, wealth and the presence of children below five years in the household. Rice-based staples which were consumed by 94.5% of respondents in the week preceding the survey had a higher likelihood of transmitting diarrhoeal diseases when consumed out of home than when eaten at home. Sources of hand-served dumpling-type foods categorized as "staple balls" had a nuanced relationship with incidence of diarrhoea. These findings reinforce the need for due diligence in addressing peculiar needs of people in vulnerable conditions of food environment in poor urban settlements in order to reap a co-benefit of reduced incidence of diarrhoea while striving to achieve the global development goal on ending hunger.

The Migration Experience and Differential Risks to Sexual and Reproductive Health in Ghana.

Background. Though internal migration in Ghana has become increasingly common in recent years, research has not focused on the gendered experiences and perceptions of migration and the association with sexual and reproductive health risks for male and female migrants. Method. A qualitative study using semistructured interviews among migrant market workers and market leaders working in Agbogbloshie in Accra, Ghana, was completed in April 2018. Interview domains for the migrant interviews included the following: expectations of migration, current working and living conditions, sexual and reproductive health, access to health care, and self-reported health status. Qualitative data were analyzed using a combination of inductive and deductive coding in MAXQDA. Results. Data indicate that migrant workers have a variety of perceptions surrounding their migration experience. In the urban destination, migrants face a number of challenges that negatively affect their health, including poor accommodation, safety concerns, and low levels of social support. Reported risks to sexual and reproductive health were unsafe sexual encounters, such as low condom use and sexual assault. Discussion. The negative sexual and reproductive health outcomes among migrant populations in urban poor settings are a result of a confluence of factors, including perceptions of destination locations, working and living conditions, social support, and gender norms. A complex systems approach to understanding the sexual health of migrants is warranted. Conclusion. Findings from this research illustrate the complexity of health risks among migrants in Agbogbloshie. Further research is needed to explore the increased vulnerability of migrants compared with nonmigrants in urban poverty and the long-term implications of sexual and reproductive health risks in vulnerable migrant communities.

Psychosocial factors and hypertension prevalence among Ghanaians in Ghana and Ghanaian migrants in Europe: The RODAM study.

Despite progress made to prevent and control hypertension, its prevalence has persisted in many countries. This study examined the associations between psychosocial factors and hypertension among Ghanaian non-migrants and migrants. Data were drawn from the Research on Obesity and Diabetes among African Migrants (RODAM) project. Findings show that among migrant women, those who experienced periods of stress at home/work had higher odds of hypertension. Among non-migrants, women with depression symptoms were more likely to be hypertensive. Furthermore, there was a positive association between negative life events and hypertension among non-migrant men. The findings highlight the importance of psychosocial factors in addressing hypertension prevalence in Ghanaian populations.

Community and individual sense of trust and psychological distress among the urban poor in Accra, Ghana.

BACKGROUND: Mental health disorders present significant health challenges in populations in sub Saharan Africa especially in deprived urban poor contexts. Some studies have suggested that in collectivistic societies such as most African societies people can draw on social capital to attenuate the effect of community stressors on their mental health. Global studies suggest the effect of social capital on mental disorders such as psychological distress is mixed, and emerging studies on the psychosocial characteristics of collectivistic societies suggest that mistrust and suspicion sometimes deprive people of the benefit of social capital. In this study, we argue that trust which is often measured as a component of social capital has a more direct effect on reducing community stressors in such deprived communities. METHODS: Data from the Urban Health and Poverty Survey (EDULINK Wave III) survey were used. The survey was conducted in 2013 in three urban poor communities in Accra: Agbogbloshie, James Town and Ussher Town. Psychological distress was measured with a symptomatic wellbeing scale. Participants' perceptions of their neighbours' willingness to trust, protect and assist others was used to measure community sense of trust. Participants' willingness to ask for and receive help from neighbours was used to measure personal sense of trust. Demographic factors were controlled for. The data were analyzed using descriptive and multivariate regressions. RESULTS: The mean level of psychological distress among the residents was 25.5 (SD 5.5). Personal sense of trust was 8.2 (SD 2.0), and that of community sense of trust was 7.5 (SD 2.8). While community level trust was not significant, personal sense of trust significantly reduced psychological distress (B = -.2016728, t = -2.59, p < 0.010). The other factors associated with psychological distress in this model were perceived economic standing, education and locality of residence. CONCLUSION: This study presents evidence that more trusting individuals are significantly less likely to be psychologically distressed within deprived urban communities in Accra. Positive intra and inter individual level variables such as personal level trust and perceived relative economic standing significantly attenuated the effect of psychological distress in communities with high level neighbourhood disorder in Accra.

Cohabitation, marriage, and 'sexual monogamy' in Nairobi's slums.

The current study investigates the extent to which sexual exclusivity--the restriction of one's sexual engagements to a single partner--prevails across various marital status, union type, and co-residence categories among Nairobi's poorest residents, slum dwellers. This question is central to the spread of HIV in the increasingly urban and poor, high prevalence countries of sub-Saharan Africa, where transmission is primarily via heterosexual sex. In many circles, sexual exclusivity is considered a prominent feature of the marriage institution. Yet, marriage and cohabitation are often not easily distinguishable in sub-Saharan Africa, meaning that the frequent use, as a proxy, of the "in union" category, which includes married as well as cohabiting persons can, at best, be considered tenuous. Using the 2000 Nairobi Cross-Sectional Slum Survey (NCSS), this paper confirms that marriage is associated with higher reports of sexual exclusivity even in settings where poverty provokes risky behavior. The finding, here, is of lower risk of HIV infection for married respondents, with a smaller effect observed among non-married cohabiters. Converse to the implied benefits of marriage, though, women with co-wives are more likely to report multiple partners. The implications of these findings are discussed.

Urban-rural differences in the socioeconomic deprivation--sexual behavior link in Kenya.

We compare the impact of socioeconomic deprivation on risky sexual outcomes in rural and urban Kenya. Quantitative data are drawn from the Demographic & Health Surveys (DHS) and qualitative data from the Sexual Networking and Associated Reproductive and Social Health Concerns study. Using two separate indicators of deprivation we show that, although poverty is significantly associated with the examined sexual outcomes in all settings, the urban poor are significantly more likely than their rural counterparts to have an early sexual debut and a greater incidence of multiple sexual partnerships. The disadvantage of the urban poor is accentuated for married women; those in Nairobi's slums are at least three times as likely to have multiple sexual partners as their rural counterparts. The implications of these findings are discussed.

Geographic mobility and potential bridging for sexually transmitted infections in Agbogbloshie, Ghana.

Short-term mobility can significantly influence the spread of infectious disease. In order for mobile individuals to geographically spread sexually transmitted infections (STIs), individuals must engage in sexual acts with different partners in two places within a short time. In this study, we considered the potential of mobile individuals as bridge populations - individuals who link otherwise disconnected sexual networks and contributed to ongoing STI transmission. Using monthly retrospective panel data, we examined associations between short-term mobility and sexual partner concurrency in Agbogbloshie, Ghana. We also examined bridging by the location of sex acts and the location of sexual partners in concurrent triads, and whether mobile individuals from our sample were more likely to be members of geographic bridging triads. Although reported rates of sexual partnership concurrency were much higher for men compared to women, mobility was only associated with increased concurrency for women. Additionally, this association held for middle-distance mobility and short-duration trips for women. Taking into account the location of sex acts and the location of sexual partners, about 22% of men (21.7% and 22.4% for mobile and non-mobile men, respectively) and only 3% of women (1.4% and 3.3% for mobile and non-mobile women, respectively) were potential bridges for STIs over the last year. Our results highlight the gendered nature of mobility and sexual risk behavior, reflecting the normative social context that encourages women to conceal certain types of sexual behavior.

Does discussion of family planning improve knowledge of partner's attitude toward contraceptives?

CONTEXT: Results from an analysis of 1998 Demographic and Health Survey (DHS) data from Kenya, where the approval rate of family planning is 90%, have cast doubt on the assumption that spousal discussion improves knowledge of partner's attitude toward family planning. However, it is not known whether this finding also applies to contexts more typical of Sub-Saharan Africa, where approval is not as high. METHODS: DHS data from 21 Sub-Saharan African countries were used to assess the relationship between spousal discussion and correct reporting of partner's attitude toward family planning. Multivariate analyses of data from Chad were conducted to further examine this relationship in a setting where contraceptive approval was not high. RESULTS: In every country, the proportion of women correctly reporting their spouse's disapproval of contraception was smaller among those who had discussed family planning with their husband than among those who had never done so. However, in an analysis of Chad data that included women who did not know their husband's attitude toward contraception, proportions of women correctly citing their husband's attitude were larger if discussion had occurred than if it had not, regardless of the husband's actual approval status. In multivariate analyses of Chad data that controlled for women's demographic characteristics, discussion was positively associated with correct reporting of husband's approval, but negatively associated with correct reporting of his disapproval. CONCLUSIONS: Partner discussion does not necessarily mean an increase in knowledge of a partner's contraceptive attitudes. Therefore, anticipated reductions in unmet need for contraception through improvements in spousal discussion may be overstated.

Urbanisation, poverty and sexual behaviour: the tale of five African cities.

The question of how urbanisation and poverty are linked in sub-Saharan Africa is an increasingly pressing one. The urban character of the HIV epidemic in sub-Saharan Africa exacerbates concern about the urbanisation - poverty relationship. Recent empirical work has linked urban poverty, and particularly slum residence, to risky sexual behaviour in Kenya's capital city, Nairobi. This paper explores the generalisability of these assertions about the relationship between urban poverty and sexual behaviour using Demographic and Health Survey data from five African cities: Accra (Ghana), Dar-es-Salaam (Tanzania), Harare (Zimbabwe), Kampala (Uganda) and Nairobi (Kenya). The study affirms that, although risky behaviour varies across the five cities, slum residents demonstrate riskier sexual behaviour compared with non-slum residents. There is earlier sexual debut, lower condom usage and more multiple sexual partners among women residing in slum households regardless of setting, suggesting a relatively uniform effect of urban poverty on sexual risk behaviour.

Sexual risk-taking in the slums of Nairobi, Kenya, 1993-8.

Relatively less attention has been paid to reproductive health problems facing deprived urban residents than to those facing rural residents in the sub-Saharan Africa. This is probably because the majority of Africans live in rural areas, where they are presumed to have poorer medical, educational, and other social services. Yet, the unprecedented rate of urbanization and the accompanying disproportionate growth in the proportion of poor city residents pose new challenges for health care in the region. This study examines differences in sexual behaviour between slum residents and non-slum residents in Nairobi city. The results show that slum residents start sexual intercourse at earlier ages, have more sexual partners, and are less likely than other city residents to know of or adopt preventive measures against contracting HIV/AIDS. The findings highlight the need to treat slum residents as a sub-population uniquely vulnerable to reproductive health problems and to expend more resources in slum settings.