Mental Health-Related Stigma and Discrimination in Ghana: Experience of Patients and Their Caregivers.

BACKGROUND: Mental health is now attracting increased public health attention from health professionals, policy makers and the general population. However, stigma and discrimination usually have enormous negative impact on the patients and their families. This study reports on stigma and discrimination faced by mental health patients and their caregivers in a suburban area of Ghana and the coping strategies used. METHOD: This is a cross-sectional exploratory study which used both quantitative and qualitative approaches. Two hundred and seventy seven mental health patients were purposively interviewed. Focus group discussions were held with caregivers and in-depth interviews were held with mental health professionals. The quantitative data were analyzed using SPSS and Microsoft Excel(®) whilst the qualitative data were coded and manually analyzed thematically. RESULTS: Mental disorder cuts across all age, sex, education, ethnicity, employment, and marital status. More females were stigmatized than males at the work/employment and educational levels. Various forms of stigma were observed at the economic, psychological and social levels, whilst for discrimination it was only observed at the economic and social levels. Caregivers were also stigmatized and discriminated. The coping strategies adopted by the mental patients and their caregivers were also economic, psychological and social in nature. CONCLUSION: Mental health patients and their families suffer from stigma and discrimination from the individual, family, work, employment, education to the health level. Thus, community level policy on mental health care needs to be developed and implemented. Furthermore mental health education needs to be intensified at the community level.

Pathways Utilized for Antenatal Health Seeking Among Women in the Ga East District, Ghana.

BACKGROUND: Ghana's maternal mortality ratio has been declining over the last two decades but at a rather slow pace. Poor access to effective maternity care is identified as one of the key challenges of maternity care. The current study mapped out the pathways to pregnancy care seeking among urban-dwelling adult women in a peri-urban district located in the Greater Accra region of Ghana. METHODS: A total of 300 women who had a live birth in the last 12 months participated in a community-based survey. They answered questions on care seeking behavior related to their last pregnancy. A multivariate Logistic regression model was used to identify factors associated with multiple care seeking behavior. RESULTS: Almost all women in the survey (98%) reported accessing skilled antenatal care (ANC) from a biomedical provider, although 35% begun ANC later than the first trimester. About 45% of women simultaneously utilized both ANC and alternative care providers (ACP) including traditional birth attendants, herbalists, and spiritualists. A complex pathway to antenatal care seeking behavior involving shuttling between providers was observed. Controlling for household wealth, household size, and age, seeking care from multiple providers concurrently was associated with residence in Kwabenya sub-district OR=2.13 (95% CI: 1.28, 3.55) and previous abortion OR=2.08 (95% CI: 1.11, 3.91). CONCLUSIONS: Urban-dwelling women in Ga East District seek antenatal care concurrently from multiple sources. Health system interventions must seek ways to integrate alternative care providers into the existing biomedical health care system.

Socio-economic differences in cost of pregnancy-related health services in the peri-urban Accra, Ghana.

BACKGROUND: Financial and physical barriers are known to limit access to maternal health services in developing countries. These limitations are often compounded by the low socio-economic status of women. This study examined socio-economic differences in health services cost incurred by pregnant women. METHODS: A cross-sectional cost survey of 300 women who had delivered a live birth in the last 12 months was undertaken. RESULTS: Majority of the women were aged between 20 and 39 years. About 63% of the women claimed they were registrants of the National Health Insurance Scheme (NHIS). However, only 64% of them provided valid NHIS identification cards. There were relatively more insured women in the rich quintiles (44%) compared with insured women in the poor quintiles (33%). Generally, women who were in the rich quintile incurred the highest average medical and non-medical costs, spent the highest time prior to service provision and lost the highest average incomes. CONCLUSIONS: Women socio-economic differences play a critical role in access to health services. We recommend that awareness campaigns on the NHIS must be intensified. The Ghana Health Services through its Community-based Health Planning Service should carefully structure its home visits to cover education on pregnancy-related health services.

Infant illness spanning the antenatal to early neonatal continuum in rural northern Ghana: local perceptions, beliefs and practices.

OBJECTIVE: To explore community understanding of perinatal illness in northern Ghana. STUDY DESIGN: A cross-sectional descriptive study design. RESULT: 253 community members participated in in-depth interviews and focus group discussions, including women with newborn infants, grandmothers and health care providers. Four overarching themes emerged: (1) Local understanding of illness affects treatment practices. Respondents recognized danger signs of illness spanning antenatal to early neonatal periods. Understanding of causation often had a distinctly local flavor, and thus treatment sometimes differed from mainstream recommendations; (2) Mothers are frequently blamed for their infant's illness; (3) Healthcare decisions regarding infant care are often influenced by community members aside from the infant's mother and (4) Confidence in healthcare providers is issue-specific, and many households use a blended approach to meet their health needs. CONCLUSION: Despite widespread recognition of danger signs and reported intentions to treat ill infants through the formal health care system, traditional approaches to perinatal illness remain common. Interventions need to be aligned with community perceptions if they are to succeed.

Trend and causes of neonatal mortality in the Kassena-Nankana district of northern Ghana, 1995-2002.

OBJECTIVES: To describe the trend and causes of neonatal deaths in a rural district in northern Ghana. METHODS: Descriptive analysis of data collected from the Navrongo Demographic Surveillance System and verbal autopsies conducted on all neonatal deaths from 1995-2002. RESULTS: Of 1118 recorded neonatal deaths 1068 (95.5%) could be analysed. Only 13.2% of deaths occurred at the health facility; 62.7% occurred in the early neonatal period, with prematurity (38%) and birth injuries (19%) as leading causes. Infectious causes (66%) were the major contributors to late neonatal deaths. Infanticide accounted for 4.9% of all neonatal deaths. The cause-specific mortality rate for neonatal tetanus remained under 2.5% throughout the 8-year period. Overall, the neonatal mortality rate declined at an average of 2.5 per 1000 live births per year: Down by nearly 50% from 40.9 (95%C.I. 34.1-46.8) in 1995 to 20.5 (95%C.I.17.3-22.7) in 2002. CONCLUSION: The various health interventions undertaken in this district have had the collateral effect of causing decline in neonatal mortality. Neonatal mortality could be further reduced by preventing and treating neonatal infections, having skilled attendance at delivery and the elimination of infanticide. Data from demographic surveillance sites may be useful in monitoring trends in child mortality.

Trends in the prevalence of female genital mutilation and its effect on delivery outcomes in the kassena-nankana district of northern ghana.

UNLABELLED: Summary RATIONAL: Female genital mutilation (FGM) is prevalent in northern Ghana, as the practice is seen as a passage rite to women adulthood and thus undertaken just before marriage. OBJECTIVES: We determined the changes in trend of FGM in deliveries at the Navrongo War Memorial hospital, and compared the outcomes and FGM status. DESIGN: Retrospective extraction and analysis of delivery data at the hospital from 1(st) January 1996 to 31(st) December 2003. RESULTS: Of the 5071 deliveries, about 29% (1466/5071) were associated with FGM. The highest prevalence (95% CI) of 61.5% (50.9, 71.2) was in women aged 40 years and above, and the lowest of 14.4% (11.7, 17.0) was in women below 20 years. The all-age prevalence of FGM showed a significant decline (p-value for linear trend < 0.01) from 35.2% in 1996 to 21.1% in 2003. About 6% (89/1466) of mothers with FGM had stillbirths compared with about 3% (123/3605) of mothers without FGM. Again FGM was associated with 8.2% (120/1466) caesarean section rate compared with 6.7% (241/3605) in mothers without FGM. Mean birth weight and frequency of low birth weights were not significantly associated with FGM status. CONCLUSION: Although there is a high rate of FGM among mothers in the district and is associated with a higher proportion of stillbirths and caesarean sections, practice has shown a significant decline in the district in recent years due to the prevailing campaigns and intervention studies. There is therefore the need to sustain the ongoing intervention efforts.

Maternal mortality among the Kassena-Nankana of northern Ghana.

This report presents key findings from a maternal mortality study conducted in the Kassena-Nankana District of northern Ghana in 1997-98. Sibling history data collected in the course of this survey are analyzed together with longitudinal data from the Navrongo Demographic Surveillance System (NDSS). A comparison between mortality data from these two sources indicates that obtaining reasonably accurate estimates of age-specific death rates is possible by using the sisterhood method. Direct and indirect estimates from the maternal mortality study and the NDSS suggest a decline in the maternal mortality ratio for the Kassena-Nankana District from 800 to 600 maternal deaths per 100,000 live births over the past 14 years.

The influence of traditional religion on fertility regulation among the Kassena-Nankana of northern Ghana.

This article presents findings from a study of the influence of traditional religion on reproductive preferences of Kassena-Nankana lineage heads in northern Ghana. Seven reproductive preference questions were administered to nine lineage heads who are primary practitioners of the cult of soothsaying. With the assistance of soothsayers, interviews were repeated in conjunction with the invocation of religious rites in order to determine the views of ancestral spirits on the seven questions. Pairs of lineage head and ancestral interviews are compared to determine the role of traditional religion in shaping male reproductive preferences. Interview pairs reflect a shared preference for sons, large compounds, and a growing lineage. Findings nonetheless show that some ancestral spirits want small families, some even wanting fewer children than corresponding lineage heads. Spiritual consultations are nondogmatic and open to external ideas and influences, suggesting that family planning introduction will not encounter systematic religious opposition among the Kassena-Nankana.

PIP: This study examined fertility preferences among male lineage heads (MLHs) among the Kassena-Nankana of Ghana and the role of traditional religion in determining fertility preferences. Data were obtained via semistructured interviews with MLHs and via contacts with ancestral spirits through soothsayers. MLHs were identified in three micropilot villages with family planning (FP) outreach services in the past year. Three heads were selected at random from the listing of lineages in each village. Interviews were conducted first in the privacy of the home and second in the sacred hut of the soothsayer, who was the medium for the ancestral interviews. Soothsayers advised their clients and participated. Paired responses of MLHs and ancestors showed considerable diversity of opinion and inconsistencies. Questions were asked about the benefits of having many children, the achievement of having the desired number of children, changes of preferences after the fact, male or female preferences, hut size preferences, approval of FP, and the benefits of health and FP service availability. Both MLHs and ancestors shared a strong preference for sons, large compounds, and a growing lineage. However, some ancestors wanted small families. Findings suggest that traditional religious practices were not a singular negative force against FP and were flexible and adaptive to social change. Ancestors acknowledged survival strategies. The methodology suggests the usefulness of communicating with men, soothsayers, and spirits about gender issues, reproductive matters, or other health issues.

Acceptability and use of insecticide impregnated bednets in northern Ghana.

A district-wide study was undertaken in a rural population of northern Ghana to identify factors influencing the acceptance and use of insecticide-impregnated bednets (IIBNs). A series of focus group discussions were conducted during 2 years of implementation of IIBNs to gauge community reactions to the introduction of the nets and a structured questionnaire was administered to approximately 2000 randomly selected individuals. Although the IIBNs were accepted and used because they provided protection from mosquito bites, seasonal factors, patterns of use, and questions of cost were key factors likely to influence the dissemination and effectiveness of bednets. Use of the bednets was highly seasonal. Almost all recipients used their IIBNs in the rainy season (99%), corresponding to the period of high mosquito density and 20% used them in the dry seasons, the period of low mosquito density. Mothers with young children were more likely to wash the bednets frequently (because the children soiled the bednets with faeces and urine), resulting in no protection from the insecticide. Provision of wider bednets, or the provision of plastic sheets with the bednets or possible incorporation of the insecticide in washing soaps could improve protection for young children. The success of the promotion of IIBNs in malaria control programmes will depend on the cost of the package and the time of year that it is delivered. Financing mechanisms for individual and village groups are discussed. Social research effectively monitored the intervention in this study, and it should be included as an important component of national malaria control programmes.

Cultural factors constraining the introduction of family planning among the Kassena-Nankana of northern Ghana.

This study presents a focus group investigation of reasons why women in a rural, Sahelian community are reluctant to adopt family planning even when convenient services are made freely available. First, women opting to practice contraception must do so at considerable risk of social ostracism or familial conflict. Implementing individual preference is something that must be done without the support of others. Second, few women view personal decisions about contraceptives as theirs to make. Women and children are the property of the corporate family-kin and community militate against reproductive control. Third, although children are highly valued for a variety of economic, social, and cultural reasons, mortality risks remain extremely high. Low fertility imposes the unacceptable risk that a woman will have no surviving children at the end of her reproductive life. Taken together, these findings attest to the inadequacy of service strategies focused on the contribution of distribution, individual agency, or personal choice. Outreach should also build a sense of community legitimacy for the program, collective health action, and traditional leadership support for family planning behavior.

Developing a culturally appropriate family planning program for the Navrongo experiment.

This article describes the first six months of the strategic planning process to develop a culturally appropriate community health and family planning program for a traditional community in a district of northern Ghana, served by the Navrongo Health Research Centre. To explain the context within which fertility decisions are made, this article describes the district's severe ecological, social, economic, and health constraints to family planning. It discusses related programmatic obstacles and presents the strategies developed to respond to them. A system of care has been developed that is closely coordinated with traditional leaders and communication networks. Management systems support outreach workers by emphasizing the importance of peer leadership, supervisory support, and community liaison in the implementation of village-based services. A large-scale experiment will be fielded to test the demographic impact of this approach.