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Akazili, James. "Equity in Health Care Financing in Ghana." Doctoral thesis, University of Cape Town, 2010. http://hdl.handle.net/11427/9390.
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Includes bibliographical references.Financial risk protection against the cost of unforeseen ill health has become a global concern as expressed in the 2005 World Health Assembly resolution (WHA58.33), which urges its member states to "plan the transition to universal coverage of their citizens". The study (the first of kind in Ghana) measured the relative progressivity of health care financing mechanisms, the catastrophic and impoverishment effect of direct health care payments, as well as evaluating the factors affecting enrolment in the national health insurance scheme (NHIS), which is the intended means for achieving equitable health financing and universal coverage in Ghana. To achieve the purpose of the study, secondary data from the Ghana Living Standard Survey (GLSS) 2005/2006 were used. This was triangulated with data from the Ministry of Finance and other ministries and departments, and further complemented with primary household data collected in six districts. In addition 44 focus group discussions with different groups of people and communities were conducted. In-depth interviews were also conducted with six managers of District NHI schemes as well as the NHIS headquarters. The study found that generally Ghana's health care financing system is progressive. The progressivity of health financing is driven largely by the overall progressivity of taxes which account for over 50% of health care funding. The national health insurance levy is mildly progressive as indicated by a Kakwani index of 0.045. However, informal sector NHI contributions were found to be regressive. Out-of-pocket payments, which account for 45% of funding, are associated with significant catastrophic and impoverishment effects on households. The results also indicate that high premiums, ineffective exemptions, fragmented funding pools and perceived poor quality of care affect the expansion of the NHIS. For Ghana to attain adequate financial protection and ultimately achieve universal coverage, it needs to extend cover to the informal sector, possibly through funding their contributions entirely from tax, and address other issues affecting the expansion of the NHI. Furthermore, the funding pool for health care needs to grow and this can be achieved by improving the efficiency of tax collection and increasing the budgetary allocation to the health sector.
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Bannister, David. "Public health and its contexts in northern Ghana, 1900-2000." Thesis, SOAS, University of London, 2017. http://eprints.soas.ac.uk/26656/.
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This is a study of the long-term political economy of public health work in northern Ghana, and of the contingent application of medical knowledge under different political regimes. Covering the period from 1900 to 2000, the thesis asks how the north and its people's enduring peripherality - defined in various ways - shaped the evolution of public health institutions and conditioned the state's attention to particular diseases. It assesses key public health transitions across the century, including the creation of the north's Native Authority health system in the 1930s, the entrenchment of church authority for healthcare in the 1950s, and the government's gradual cession of medical oversight to international organisations from the late 1960s, a process which was partially reversed in the late 1990s. It examines specific disease control programmes against sleeping sickness, onchocerciasis, and guinea worm, for what they reveal about the social history of medical work on the margins of the state, and about the political contexts for population-level health interventions. Colonial-era tsetse control inadvertently contributed to the serious prevalence of onchocerciasis in the north at independence, and this high prevalence of onchocerciasis made northern Ghana a focus of international health fundraising ahead of the WHO Onchocerciasis Control Programme, which began in 1974. In the urban south, guinea worm disease was substantially reduced in the early twentieth century, but in the north the disease only received concerted attention from the 1980s. In the historical literature on health in Ghana, there are few studies which adequately disaggregate the north and its particular experiences of public health work. Using sources from northern regional archives, the archives of the World Health Organisation, and interview testimony from government health officials and village communities, the thesis aims to make a contribution to this area.
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Burchett, Helen. "Perceptions of the usefulness of public health research in Ghana." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2010. http://researchonline.lshtm.ac.uk/682424/.
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This study aimed to explore researchers' and policy stakeholders' perceptions of the usefulness of public health research for policy, using the example of maternal health in Ghana. Sixty-nine government decisionmakers, maternal health policy stakeholders and researchers were interviewed. Concepts of research were broad. Research was dichotomised into `big', formal research and 'small', applied research such as operations research. 'Small research' was highly valued, due to its speedy completion and its focus on topics pertinent to service delivery; big research was not always considered necessary. Effectiveness research, one type of `big research', was not highly valued. Interviewees tended to feel that 'effective' policies and programmes could be designed once there was a thorough understanding of the situation. There was an implicit assumption that as long as these interventions were implemented well, they would be effective. Six dimensionso f local applicability/transferabilitwye re identified.T he most influential factors were the ease with which the intervention could be implemented, the study's congruence with interviewees' previous experiences and the perceived need for the intervention. Little attention was paid to study findings. Judgements of an intervention's potential effectiveness tended to be based on the ease of implementation or knowledge of similar projects. Adaptation was considered to be crucial, although often conceptualised not as a factor within local applicability/transferability assessments, but rather a distinct, essential step in the research use process. This study suggests that the factors of local applicability/transferability frequently cited in the literature do not reflect those considered to be most important by stakeholders in Ghana.
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Agyeman-Yeboah, Joana. "A best-practice guideline for facilitating adherence to anti-retroviral therapy for persons attending public hospitals in Ghana." Thesis, Nelson Mandela University, 2017. http://hdl.handle.net/10948/13603.
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The retention of persons on an HIV programme has been a global challenge. The success of any strategy to optimize adherence to anti-retroviral therapy (ART) depends on the intensive and effective adherence counselling and strategies. It is important to research whether persons receiving anti-retroviral therapy in public hospitals in Ghana are receiving the needed service that would optimize their adherence to the anti-retroviral therapy. Therefore, this study explored and described the experiences of healthcare professionals providing care, support and guidance to persons on ART at public hospitals in Ghana, as well as the best-practice guideline that could contribute to facilitating the ART adherence of patients. This study also explored and described the experiences of persons living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) on ART, regarding their adherence to the therapy. The study was organized into three phases. In Phase One: a qualitative, exploratory, descriptive and contextual design was employed. The research population included healthcare professionals, providing services at the HIV clinic at the public hospitals in Ghana, namely the Korle-Bu Teaching Hospital; the 37 Military Hospital and the Ridge Hospital. The healthcare professionals comprised of doctors, nurses, pharmacists and trained counsellors employed in any of the three public hospitals. Persons receiving ART at any of the three public hospitals were also part of the research population. Semi-structured interviews were conducted with healthcare professionals and persons receiving ART. Data were collected from healthcare professionals in relation to their experiences regarding the provision of ART services, their understanding of evidence-based practice and best-practice guidelines, as well as data on the experiences of persons receiving ART in relation to their adherence to the therapy. The data were analysed using Creswell’s six steps of data analysis; and the coding of the data was done according to Tesch’s eight steps of coding. Trustworthiness was ensured by using Lincoln and Guba’s framework which comprised credibility, transferability, dependability, confirmability and authenticity. Ethical principles such as beneficence and non-maleficence, respect for human dignity, justice, veracity, privacy and confidentiality were considered in the study. In phase two, the literature was searched by using an integrative literature review approach and critically appraising the methodological quality of the guidelines in order to identify the best available evidence related to adherence to ART. In Phase Three, a best-practice guideline for facilitating adherence to ART was developed for public hospitals in Ghana based on the findings of the empirical research of Phase One and the integrative literature review in Phase Two. The guideline was submitted to an expert panel for review; and it was modified, according to the recommendations of the panel.
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Amediavor, Rita Laryea. "The Persisting Threats Of Cholera: A Cyclical Public Health Problem In Ghana." Wright State University / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=wright1598992794308852.
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Mensah, Gwendolyn Patience. "Best practice guideline for the nursing management of women with gestational diabetes mellitus in military health institutions in Ghana." Thesis, Nelson Mandela University, 2017. http://hdl.handle.net/10948/14036.
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Pregnancy is a normal physiological process for the majority of women. These women, their families and significant others normally expect a successful period of pregnancy, labour, delivery and arrival of a normal and healthy baby. However, some of these pregnant women may develop Gestational Diabetes Mellitus (GDM) during this period and if not managed properly, the mother and the foetus in utero are affected in a negative way: there is a likelihood of the mother and baby developing Type 2 Diabetes in the future and also, other risks such as preterm labour, and foetal macrosomia. In order to prevent such occurrences, I set out to develop a best practice guideline for the nursing management of GDM in military health institutions in Ghana in order to help enhance nursing care. The design for this research was qualitative, explorative, descriptive and contextual in nature. The research is organised in three phases: Phase one deals with the data analysis and discussion of the interviews with professional nurses and midwives and women with a history of GDM. The data collected from the interviews were transcribed, analysed and extracted with Tesch’s eight steps of coding used for the coding. The services of an independent coder were employed to assist with the coding process which led to the formulation of key themes. Semi-structured individual interviews provided a means of exploring the perceptions of professional nurses and midwives on the nursing management of GDM: in addition, women with a history of GDM were interviewed so as to elicit their views on the management they had experienced from professional nurses and midwives before and after being diagnosed with GDM. The trustworthiness of the study was ensured by conforming to Lincoln and Guba’s framework of credibility, transferability, dependability, confirmability and authenticity. An independent coder assisted with the coding process. Phase two deals with the Integrative literature review of available evidence-based clinical practice guidelines for the nursing management of GDM. Evidence-based clinical practice guidelines were searched and appraised with assistance from an independent appraiser and themes were then formulated. In Phase three, the themes from Phase one and Phase two were integrated for the development of a draft best practice guideline for the nursing management of GDM in military health institutions in Ghana. The draft guideline was given to an expert panel of reviewers for their comments and recommendations. These were considered in the development of the final best practice guideline for the nursing management of GDM.
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Arku, Raphael E. "Poverty, Energy Use, Air Pollution and Health in Ghana: A Spatial Analysis." Thesis, Harvard University, 2015. http://nrs.harvard.edu/urn-3:HUL.InstRepos:16121156.
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Some of the major themes that characterize the relationship between the environment and population health in the developing world today include poverty, household access to clean cooking fuel, air pollution, sanitation, and infant/child and maternal health. My dissertation research incorporates some of these themes at the interface of community and household energy in the context of economic development in Ghana. Specifically, my dissertation focuses on features of household energy and poverty in both rural and urban areas, as well as air pollution, and child and maternal health in growing urban areas in what is a data and resource-poor setting of Sub‐Saharan Africa (SSA).
Child mortality is declining in most countries. Very few studies have measured child mortality at fine spatial resolutions, which is relevant for assessing community determinants and interventions. The first paper evaluates subnational inequalities in child mortality and its social and environmental determinants in Ghana by applying Bayesian spatial model to Ghana’s 2000 and 2010 National Population and Housing Censuses in 2000 and 2010. The census data were also used to estimate the distributions of households or persons in each of Ghana’s 110 districts for fuel used for cooking, sanitation facility, drinking water source, and maternal and paternal educations. Median district 5q0 declined from 99 deaths per 1,000 live births in 2000 to 70 in 2010. The decline ranged between <5% in some northern districts, where under-five mortality had been higher in 2000, to >40% in southern districts, where it had been lower in 2000, leading to higher inequalities. Primary education increased in men and women and more households had access to improved water and sanitation and cleaner cooking fuels over the same period. Higher use of liquefied petroleum gas for cooking was associated with lower 5q0 in multivariate analysis. Associations for the other social and environmental variables were not consistent or were weak in the different analyses although there were indications of beneficial effects from replacing wood with charcoal or kerosene, from improved sanitation (but not water), and from higher share of mothers and fathers with primary education.
The second paper examines personal particulate matter exposures and locations of 56 students from eight schools in four neighborhoods in of varying socioeconomic status in Accra, Ghana, using gravimetric and continuous PM2.5 data, with time-matched global positioning system coordinates. Personal PM2.5 exposures ranged from less than 10 μg/m3 to more than 150 μg/m3 (mean 56 μg/m3). Girls had higher exposure than boys (67 vs. 44 μg/m3; p-value = 0.001). Exposure was inversely associated with distance of home or school to main roads, but the associations were not statistically significant in the multivariate model. Use of biomass fuels in the area where the school was located was also associated with higher exposure, as was household’s own biomass use. Paved schoolyard surface was associated with lower exposure. School locations in relation to major roads, materials of school ground surfaces, and biomass use in the area around schools may be important determinants of air pollution exposure.
The third paper assesses the feasibility of using hospital administrative records for understanding air pollution health effects on pregnancy outcomes in Accra. This evaluation addresses whether: (i) the available health administrative data can be used to assess PM pollution-related adverse pregnancy outcomes, in particular birth weight; (ii) the health administrative structure and data can be used in the design of follow-up studies in such settings; (iii) the number of births that occur in the city would provide a large enough sample size; and (iv) birth weight distribution in such complex source-pollution environments varies substantially across neighhorhoods. There are six health districts in the Accra metropolis. In addition to other government and private facilities, each district is served by a Government polyclinic, where maternal and child health records in the district are collated. Neonatal and maternal health records, including anthropometric and demographic information are primarily kept by the individual women in cards provided by the Ghana Health Services. There are an estimated 10,000 births annually in each district. The average birth weight across selected facilities was 3,167±458 g, with individual birth weights ranging from 1,200 g to 6,000 g. Mean birth weight was similar across polyclinics. More than 95% of expectant mothers received at least 4 antenatal care visits at a health facility. Child immunization for the full range of vaccines covers over 80% of children born in the metropolis. A retrospective study of the association of air pollution exposure and birth weight in Accra through the use of hospital administrative records is feasible provided mothers are targeted through the public health units, which is responsible for child immunization.Environmental Health
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Kutufam, Doreen Vivian. "Gendering of health communication campaigns in Ghana cultural relevancy and social identity /." Related electronic resource:, 2007. http://proquest.umi.com/pqdweb?did=1375538411&sid=1&Fmt=2&clientId=3739&RQT=309&VName=PQD.
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Baidoo, Rhodaline. "Toward a Comprehensive Healthcare System in Ghana." Ohio University / OhioLINK, 2009. http://rave.ohiolink.edu/etdc/view?acc_num=ohiou1237304137.
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Hill, Emilie. "Master of Public Health Research Project: Unmarried Women in Ghana, Africa: Predictors of Condom Use- An Analysis of the 2008 Ghana Demographic and Health Survey/Questionnaire Database." VCU Scholars Compass, 2010. http://scholarscompass.vcu.edu/etd/2069.
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Background: Many factors affect whether women will insist that their sexual partners use a condom. This research project will identify some of the predictors of condom use among unmarried women in Ghana, Africa. Methods: This research project evaluated data from the 2008 DHS of women in Ghana, Africa for predictors of condom use among unmarried women. A total of 4,916 women completed the surveys. Of these, 1,966 women were unmarried. The research project employed multiple logistic regression analysis to determine condom use predictors at the time of the last sexual encounter for these 1,966 unmarried women. Results: Women with a secondary education or beyond were 3.2 (95% CI=2-5.2) times more likely to have insisted on the use of a condom than women with a primary education or less. Women ages 15-24 were 5.3 (95% CI=2.5-11.3) times more likely to have insisted on the use of a condom than women ages 35-49. Women ages 25-34 were not significantly different than the women ages 35-49. Women living in an urban area were 1.8 (95% CI=1.3-2.5) times more likely to have insisted on the use of a condom than women living in a rural area. Women with a higher level of literacy (could read a full sentence) were 3.6 (95% CI=2.5-5.1) times more likely to have insisted on the use of a condom than women with a lower level of literacy (were unable to read a full sentence). And in concert, women who read a newspaper or a magazine once a week or more were 2.4 (95% CI=1.6-3.5) times more likely to have insisted on the use of a condom than women who read a news paper or a magazine less than once a week. Similarly, women who watched television once a week or more were 2.9 (95%CI= 1.9-4.3) times more likely to have insisted on the use of a condom than women who watched less than once a week. Women who were determined to have “excellent” knowledge about HIV were 5.8 (95% CI=1.5-22.3) times more likely to have insisted on the use of a condom than women who were determined to have “fair or poor” knowledge. The results for women with a “good” knowledge were not significantly different than for those with “fair or poor” knowledge. Women who were determined, through a series of questions about wife beating, to have a low tolerance for abuse towards women (“strong” attitude about domestic violence/women’s rights) were 1.8 (95% CI=1.2-2.7) times more likely to have insisted on the use of a condom than women who were determined to have a high tolerance for abuse towards women (“poor” attitude about domestic violence/women’s rights). Results for women with a “fair” attitude were not significantly different from those with a “poor” attitude. Total life time sexual partners, frequency of listening to the radio, and interestingly, access to condoms did not significantly affect condom use. After multivariate adjustment, the significant predictors of condom use at the time of last sexual encounter were age, literacy, and amount of television watched. The results were: women age 15-24 (compared to women ages 35-49), women who could read a full sentence, and women who watched television once a week or more were 3.7 (95% CI=1.7-8.1), 2.1 (95% CI=1.4-3.3), and 1.8 (95% CI=1.2-2.8) times more likely to have insisted on the use of a condom during their last sexual encounter, respectively. Conclusion: Education, age, locality, literacy, media exposure (through reading the news paper or a magazine and watching television), knowledge about HIV, and attitude about domestic were predictors of condom use by the sexual partner of unmarried Ghanaian women at the time of last sexual encounter. After multivariate adjustment, only age, literacy, and amount of television watched were significant predictors of condom use at the time of the last sexual encounter.
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Kpodotsi, Aseye. "Socioeconomic inequalities in the use of skilled birth delivery during childbirth in Ghana: a decomposition model." Master's thesis, University of Cape Town, 2018. http://hdl.handle.net/11427/29388.
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Equitable access to, and use of skilled birth attendance during delivery is vital for the achievement of the Sustainable Development Goals (SDGs) in reducing global maternal deaths to 70 deaths per 100, 000. Although several initiatives have been implemented to reduce maternal mortality in Ghana, inequities in the use of skilled birth attendance during delivery still exist among women of different socioeconomic groups. This study assessed the socioeconomic inequalities and the underlying factors related to the inequalities in the use of skilled birth attendants during delivery in Ghana. This study analysed data from the 2014 Ghana Demographic and Health Survey (GDHS) using a decomposable health concentration index. Concentration index (CI) and concentration curves were employed to measure the magnitude of socioeconomic inequality in the use of skilled birth attendants during child delivery. The concentration index was decomposed to identify the underlying factors causing the inequalities. Out of a total of the 1,305 women who gave birth in the year prior to the interview, 28% of the deliveries had no skilled birth attendants of which 60% lives in rural compared to 40% in urban. A concentration index of 0.147 showed a pro-rich utilization of skilled birth attendance during delivery. The decomposition analysis revealed that, wealth, education and location of residence were the major contributors to socioeconomic inequalities in the use of skilled birth attendants during child delivery among Ghanaian women. This study suggests that factors such as wealth, area of residence and education are worthy of increased attention in programmatic efforts, and policy interventions, because they are amenable to the reduction of observed inequality.
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Chebere, Margaret. "An evaluation of Human Resources managerial effectiveness of the public health sector of Ghana." Thesis, University of Manchester, 2011. https://www.research.manchester.ac.uk/portal/en/theses/an-evaluation-of-human-resources-managerial-effectiveness-of-the-public-health-sector-of-ghana(1b1e6d47-af08-4881-a79b-26946445d8e5).html.
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The objective of this research is to evaluate Human Resources managerial/development effectiveness (HRM/DE) of frontline managers from the perspectives of managers themselves and stakeholders in the public health sector (PHS) of Ghana. The study did this through the development of a conceptual framework which combined the use of integrated organisational and management theoretical perspectives and contextual variables. The study employed the mixed methods research methodology which combined both empiricism and post post-positivists' views with critical realism as the underpinning philosophy. A total of 18 district directors of health, from two regions were purposively sampled and interviewed utilising an in-depth open ended questionnaire through the discussion. Additionally, key policy makers were interviewed and focus group discussions held and a structured questionnaire completed by another group of employees, who assessed managers' capabilities. Discourse analysis was used for the analysis with the aid of Nvivo 7 for the qualitative material whilst quantitative data were analysed using simple descriptive statistics. Findings were triangulated using Marquart and Zercher's (2000) cross-over track analysis framework. Findings show research questions were answered. Majority of district directors lack managerial competencies; are less interested in HRM/D activities, less confident of their human resource skills and less sure of the political and representational skills required of managers. In particular, it is necessary to take account of the political structure of the PHS of Ghana; significant differences exist in power, individual or group interests, values, assumptions and expectations. However, most district directors have tried to indigenise HRM/D practices as a way of motivating and retaining staff. Core Human resources managerial competencies from the perspectives of the three sampled groups have been compiled. It is the first time such a study has been conducted in the PHS of Ghana and which has therefore made inroads in the existing literature and has contributed to HRM/D literature information in Africa particularly Ghana. It also paves the way for understanding management in the African context and perspective and specifically in health care settings. This study has gone beyond the two groups of respondents and proved that the use of multiple respondents generates rich findings and unveiled what would normally have not been possible if single respondents were used.
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Danso, Collins Akuamoah. "Critical evaluation of the role of community based health insurance schemes in extending health care coverage to the informal sector in Ghana." Master's thesis, University of Cape Town, 2006. http://hdl.handle.net/11427/9343.
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Includes bibliographical references (leaves 83-92).One major challenge facing the international development community is how to finance and provide health care for the large informal sector in low and middle income countries. This is as a result of the inability of the traditional tax systems in most of these countries to generate the needed revenue to help meet the health needs of the citizens. In recent times, many countries in developing countries are increasingly depending on Community Based Insurance Schemes (CBHIS) as an alternative health care financing mechanism. In Ghana. the universal tax funded system of health care introduced in 1957 soon alter independence could not be sustained because of economic recession in the 1970's and 1980's forcing the government to introduce user fees in all public health institutions. User fees resulted in a decline in utilization of health services especially the poor and vulnerable group. This situation forced many communities to set up CBHIS meant to cover user fees charged at the health facilities. The success of some of these schemes and the fact that many Ghanaians do not have insurance cover led the government to introduce a National Health Insurance Scheme (NHIS) which is mandatory for all citizens. The law mandates all formal sector workers to contribute part of their social security contribution to the National Health Insurance Fund as premium, thus making it compulsory for them. Those in the informal sector are however required to voluntarily pay directly into their district schemes. Also, even though a proposal has been made to exempt the poor, no mechanism has been determined to identify poor households for subsidy. This study sought to undertake a critical evaluation of the role of CBHIS under the NHIS in extending health care coverage to the large informal sector (who are about 70% of the active labour force) in Ghana. Specifically, the study sought to determine factors that affect enrolment, to determine a practical mechanism to identify the poor and to gain an understanding of how other countries have increased health insurance coverage.
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Larbi, George Addo. "Implementing new public management reforms in Ghana: Institutional constraints and capacity issues: cases from Public health and water services." Thesis, University of Birmingham, 1998. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.520505.
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New Public Management has become an accepted term in the public administration and management literature, and the reforms it describes are increasingly being advocated in developing countries. This thesis examines the institutional constraints and capacity issues in introducing and implementing downsizing, decentralised management, performance contracting and contracting-out as instances of new public management reforms in health and water services in Ghana. The central argument of the thesis is that reformers tend to overemphasise issues of what to implement and underemphasise issues of how to implement and, in the process, tend to overlook contextual and institutional factors that may affect implementation. It uses data from in-depth and semi-structured interviews, varieties of documentary sources and direct observations, and adopts a multi-theoretical framework which draws upon implementation and principal-agent theories. The study provides evidence to show that, except for downsizing, new public management reform is still embryonic and fragile, yet to be consolidated. Within the limited progress made in implementation, however, there is evidence that the structural components of the reforms have advanced more than the operational aspects. Health has made more progress in decentralisation than the water organisation, whilst the latter is ahead in downsizing and performance contracting. It further shows that systemic, governance-grounded constraints are more binding on capacity to implement and manage reforms. The introduction and implementation of new management reforms need to take account of the operational reality and context of the public services in Ghana. Implementation needs to be managed and cannot be taken for granted.
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Denton, Curtis James. "Estimating Buruli Ulcer Prevalence in Southwestern Ghana." Thesis, University of North Texas, 2007. https://digital.library.unt.edu/ark:/67531/metadc3981/.
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Mycobacterium ulcerans is sweeping across sub-Saharan Africa, but little is known about the mode of transmission and its natural reservoirs. Since the only effective treatment is excision of the infection and surrounding tissue, early diagnosis and treatment is the only way to reduce the havoc associated with Buruli ulcer. Using data from a national case search survey conducted in Ghana during 2000 and suspected risk factors this study tests the hypothesized factors and probes the challenges of developing a spatial epidemiological regression model to explain Buruli ulcer prevalence in the southwestern region of Ghana representing 42 districts. Results suggest that prevalence is directly related to the degree of land cover classified as soil, elevation differential, and percent rural population of the area.
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Lanthorn, Heather Elisabeth. "Achieving Access to Antimalarials: Views From Ghana on the Political-Economy of Adopting and Implementing the Affordable Medicines Facility-Malaria (AMFm)." Thesis, Harvard University, 2016. http://nrs.harvard.edu/urn-3:HUL.InstRepos:25757887.
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My research examines the adoption and implementation processes involved in transferring a global health policy into national-level practice. More specifically, I consider how high-level stakeholders adopted and street-level, private-sector retailers implemented the Phase I pilot of the Affordable Medicines Facility- malaria (AMFm) between mid-2009 and end-2011. The AMFm — a large-scale program housed at the Global Fund to Fight AIDS, TB and Malaria — sought to improve access to high-quality malaria treatment through financing and delivery strategies using the public and private sectors. To date, the median implementation outcomes have been considered in the Independent Evaluation commissioned by the Global Fund but country-level processes and nuanced considerations of outcomes have gone unexplored. To better understand the AMFm pilot in Ghana, I collected both quantitative and qualitative data between August and December 2011.
To consider adoption, I first use a grounded, qualitative approach to address: What explains the stands taken by national stakeholders towards and against participating in the AMFm’s Phase I? I generate explanatory categories about the different views — stands — key stakeholders in Ghana took about joining Phase I. Public health goals; indirect policy goals; and concerns about personal, organization, and national reputation help to explain the views of different high-level stakeholders. Second, I consider the actions taken by different stakeholders: To what extent can a multiple-streams approach to policy adoption help clarify Ghana’s decision to join in the AMFm’s pilot? I find the Multiple-Streams Approach cannot be used to explain adoption of the AMFm pilot in Ghana. However, a modified version accounting for the global and national levels simultaneously can explain this case.
To consider implementation, I ask: Do retailers in Northern Region comply with Ghana’s the advertised AMFm Recommended Retail Price among for-profit, private-sector retailers? And, does non-compliance vary systematically with features of retailer structure or conduct? I find high compliance based on reported retail prices. I also find that neither measures of spatial competition nor having seen regulation enforced in the past explain the pattern of non-compliance. Rather, variation in the terminal supply price is highly associated with a retailer’s decision to charge at or above the RRP.
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Doku, Paul Narh. "The mental health of orphans and vulnerable children within the context of HIV/AIDS in Ghana." Thesis, University of Glasgow, 2012. http://theses.gla.ac.uk/3629/.
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Background: The HIV/AIDS epidemic has contributed to a drastic increase in the number of orphans and vulnerable children in sub-Saharan Africa. However, little is known about the mental health of these children in low prevalence areas such as Ghana. The thesis investigated the relationship between orphanhood, parental HIV/AIDS status and mental health. It further examined the mediating effects of identified risk and protective factors on the relationship between orphanhood/parental HIV/AIDS status and psychological difficulties. Finally, the thesis identified pathways through which HIV/AIDS impacts children by exploring the interactive and cumulative effects of the various risk and protective factors on psychological difficulties. Method: The thesis employed cross-sectional, quantitative interviews that involved 291 children aged 10-18 years and their caregivers that compared children who have lost their parents to AIDS, those who have lost their parents to other causes, those who are living with HIV/AIDS-infected caregivers and children from intact families in the Manya Krobo district in Ghana. ANOVAs, T-tests, General Linear Models, Log-linear Analyses, Chi-Squares and Bivariate Correlations were used to analyze the data that were obtained from both the children and their caregivers. Results After controlling for relevant socio-demographic factors, both children and informants’ reports showed that children orphaned by AIDS and those living with infected parents showed higher delinquency (p <.01), peer problems (p <.001), hyperactivity (p <.01) and lower self esteem (p <.001) than other orphans and children from intact families. AIDS orphans, other orphans and those living with HIV/AIDS-infected parents all reported significantly more depression (p <.001) and relationship problems (p <.001) than those for intact families. Conduct problems as indicated by informants’ reports were generally, significantly higher for orphans and vulnerable children compared to children from intact families. Over 70% of both AIDS orphans and children living with infected parents showed internalising symptoms that were above clinical cut-offs for abnormality. AIDS orphans and children living with infected parents reported more stigma, abuse, child labour and lower levels of SES and lower perceived social support. These factors independently, strongly mediated the relationship between orphanhood, parental HIV/AIDS status and mental health. The interactive and cumulative effect of engagement in child labour and being physically abused heightened the risks for depressive symptoms from 38% to 66%. Neglect and psychological abuse increased the risks for symptoms of Reactive Attachment Disorder from 26.6% to 67.3%. The cumulative effect of stigma and either child labour or physical abuse substantially increased the likelihood of delinquency symptoms to approximately 67%. Conclusion: The findings demonstrated that both AIDS orphans and children living with HIV/AIDS-infected parents showed heightened psychosocial symptoms. The present evidence also highlighted the interactive, cumulative, co-occurrence of contextual factors and HIV/AIDS unique exposures to create heightened vulnerabilities for psychological difficulties among children. The findings call for a comprehensive intervention programme that addresses factors specific to HIV/AIDS and contextual variables.
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Akweongo, Patricia. "Measuring equity in access to health care : a case study of malaria control interventions in the Kassena-Nankana district of Northen Ghana." Doctoral thesis, University of Cape Town, 2005. http://hdl.handle.net/11427/9346.
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Includes bibliographical references (leaves 236-251).This thesis develops a methodology for measuring equity in access to health care. The thesis deconstructs the concept of access into dimensions that represent the supply and demand side of health care and tests each of these dimensions by using the example of access to malaria services in the Kassena-Nankana district of northern Ghana. An innovative framework and a disadvantage index are developed herein, and are used to analyse the primary factors of access and to measure inequities in such access. A cross-sectional survey of 1880 household heads, focus group discussions, in-depth and key informant interviews with community members and health providers were used to explore issues in respect of malaria management, health care access and perceptions of poverty. The principal component and factor analysis statistical methods were then applied to estimate access factors and to compile a disadvantaged index of access. The key findings indicate that the dimensions, availability, affordability, information and acceptability primarily determine access to health care. On the availability dimension, physical distance to health care, provision of primary and inpatient are and travel distance are significant factors. The primary factors of affordability are associated more with the socio-economic characteristics of the household than with direct user costs. The information dimension is determined primarily by knowledge to treat levels of severity of malaria and the source of information for treatment. The acceptability of health care is related to methods and services for managing severity of levels of malaria at home as well as using qualified health care providers. The disadvantage index and poverty maps show significant disparities in health care access between geographic areas and socio-economic groups', with areas in the outskirts of the Kassena district being the most disadvantaged in terms of availability, acceptability and information. These areas are however not economically disadvantaged. The poorest households have the lowest accessibility scores across all dimensions.
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Annor, Francis Boateng. "An Examination of the Association between HIV-related Knowledge, Attitudes, and Behaviors and HIV Infection Status in Ghana." Digital Archive @ GSU, 2009. http://digitalarchive.gsu.edu/iph_theses/128.
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The reduction in HIV prevalence in Ghana has been attributed to the increased awareness about the disease which has significantly caused changes in behavior to reduce the people’s risk of HIV infection. The purpose of this study was to explore the effects of some selected demographics variables on HIV-related knowledge, attitude and behavior and also to examine the effect of HIV related knowledge, attitude and behavior on HIV serostatus in Ghana. Using data from Demographic Health Survey on Ghana for 2003, binary and multivariable logistic regression analysis was conducted. The results indicated that increasing educational level, increasing wealth and residing in the urban areas were all significantly associated with high HIV knowledge, positive attitude and the practice of less risky sexual behavior. The results also showed that HIV negative individuals were more likely to have higher HIV knowledge, have negative attitude towards people living with HIV and to practice less risky sexual behaviors though none of these was statistically significant.
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Bayer, Chris N. "The effects of child labor monitoring on knowledge, attitude and practices in cocoa growing communities of Ghana." Thesis, Tulane University, Payson Center for International Development, 2014. http://pqdtopen.proquest.com/#viewpdf?dispub=3616538.
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Among the multitude of interventions to address the worst forms of child labor (WFCL), one of the responses to the presence of WFCL has been the institution of child labor monitoring (CLM). While systems to systematically monitor children with respect to their exposure and risks have been implemented, the degree of their efficacy and ultimately their effect on the targeted populations begs academic scrutiny. This dissertation seeks to provide an empirical view of the community-level dynamics that emerge in response to a community-based CLM program and their effects, in turn, on the CLM itself.
An embedded multiple case study methodology, surveying longitudinally at two points in time using a mix of purposive and probability sampling techniques, was employed for this study. Two communities, Ahokwa in the Western Region, and Dwease in the Ashanti Region of Ghana, were selected as cases.
The study finds that between the two points of observation – before and after the introduction of CLM – a profound reduction of WFCL is observed in Dwease, whereas much less reduction was observed in Ahokwa. A point-by-point analysis within and between the two villages reveals that individual, social and institutional factors worked together to transform behavior in Dwease. The principal change catalysts in Dwease were (a) a heightened awareness of child work hazards and a deepened parental investment in child education working at the individual level, coupled with (b) new norms created by the town's opinion leaders and the emergence of peer accountability at the social level, and (c) monitoring carried out by the Community Data Collection (CDC) and enforcement carried out by the Community Child Protection Committee (CCPC) – the two new institutions constituting CLM at the community-level. The underlying social dynamic proved to be decisive: a tipping point was crossed in Dwease whereby progressive opinion leaders in the community, who, once sensitized to recognize the pejorative effects of CL/WFCL, created new social norms and spurred a critical mass of community members to rid their community of CL/WFCL.
This study shows that with sufficient local ownership, and if properly instituted, the tandem operation of child protection committees and child labor monitoring enables a community to effectively detect, police and mitigate the practice of child labor and WFCL.
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Adamtey, Ronald. "Devolution and deconcentration in action : a comparative study of five Municipal Health Directorates in Ghana." Thesis, University of Sussex, 2012. http://sro.sussex.ac.uk/id/eprint/39583/.
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Decentralisation policies have been adopted by most countries in Sub-Saharan Africa in the expectation of improved service provision. The benefits expected are two-fold: a) decentralisation will lead to better coordination and collaboration between different parts of the state at the local level and b) decentralisation will lead to increased consultation and responsiveness of local governments to their citizens. In this thesis I seek to explain why these benefits are realised in some contexts and not others. In most parts of Sub-Saharan Africa, the predominant form of decentralisation is a combination of devolution and deconcentration. Often these two policies are ambiguous and sometimes contradictory. What are the processes through which such mixed systems work? This thesis attempts to understand how mixed systems of devolution and deconcentration work in practice through a comparative study of Five Municipal Health Directorates in Ghana. The study explores the three sets of relationships that are critical for decentralisation to work well in such mixed systems a) between the Health Directorate and the District Assembly administration, b) between the Health Directorate and the elected members of the District Assembly and c) between the Health Directorate and selected civil society organisations working on health. The work is based on detailed qualitative interviews in the five municipalities. The main finding is that informal ties between the Health Directorate and the three sets of actors mentioned above are helpful in explaining why coordination and consultation seem better in some municipalities than others. Four kinds of ties are found to be important: ethnic/tribal links, family/kinship/neighbourhood relations, political party affiliations, and old-school networks. These ties between Municipal Health Directorates and senior officers of the Municipal Assemblies were found to facilitate Municipal Health Directorates' access to District Assemblies' Common Fund, which was controlled by the Municipal Assemblies. The existence of these ties between Municipal Health Directorates and elected Assembly members of Municipal Assemblies were found to enhance the quality of Municipal Health Directorates' policies and helped to gain public support. Finally, such ties between Municipal Health Directorates and leaders of selected Civil Society Organisations that mobilised around HIV and AIDS programmes were found to facilitate implementation of Municipal Health Directorates' policies around HIV and AIDS. The thesis' contribution is that it shows that informal linkages between different local bodies and between local government and civil society organisations seem important for improved coordination and collaboration among various actors, and better consultation with elected representatives of citizens and leaders of CSOs for effective service delivery at the local level.
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Eghan, Edmund Sekyi. "Factors Associated With Maternal Mortality in Greater Accra Ghana 2016: Case-Control Study." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7921.
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Maternal mortality is a critical area of concern globally, despite the availability of accessible preventive measures. The role of sociodemographic and service delivery factors in maternal mortality in the Accra Metropolitan Area of Ghana are important to examine. As part of the United Nations (UN) Millennium Campaign, the UN implemented 8 Millennium Development Goals (MDGs); maternal mortality reduction by 75% between 1990 and 2015 was among the fundamental MDGs to be achieved by 2015. The purpose of this case-control study was to use secondary data to assess the relationships between sociodemographic variables, service delivery factors, and maternal mortality among 8,171 women of reproductive age (15-45 years) living in the Greater Accra metropolitan area in Ghana. The health belief model and social cognitive theory provided the theoretical framework to interpret the study findings. Particularly, income (p = .023), primary (p = .035) and secondary (p = .002) education, and health insurance (p = .008) were significantly associated with maternal-related mortality. However, for survival outcome, health insurance (p = .003), prenatal care (p = .001), and presence of a skilled attendant at delivery (p = .020) were significant factors. These study results provide support for the significant effects of sociodemographic and service delivery factors on maternal mortality and survivorship in the Greater Accra metropolitan area in Ghana. The results of this study could enhance educational and outreach programs designed to lower maternal mortality rate. Further research needs to be done to advance knowledge and practice in health delivery services and public health education with respect to the importance of sociodemographic and service delivery characteristics.
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Kyei, Kofi Adesi. "Assessment of Anxiety and Depression Among Breast Cancer Patients Undergoing Treatment in Ghana." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4526.
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Breast cancer patients undergoing radiotherapy often experience severe levels of anxiety and depression. There is a gap in the research literature from Africa, particularly from Ghana, with few studies focusing on the assessment of anxiety and depression among breast cancer patients undergoing radiation treatment. A better understanding was essential to promote efforts to help breast cancer patients cope with their diagnosis and treatment and increase their overall quality of life. This mixed method study examined breast cancer patients in Ghana undergoing radiotherapy and their responses related to anxiety and depression through a concurrent triangulation involving an interview with selected professional participants and a detailed patient survey. Patients completed 2 modified scales, the Patient Health Questionnaire and Depression Anxiety Stress Scale. The sample consisted of 100 patients between the ages of 20-89. Individual interviews were held with 6 professionals with a minimum of 5 years of work experience. Themes were generated through open coding of the interview data, while multiple regression was performed to determine the relationship between depression and anxiety with the independent variables . Findings of this study indicated the need intervene through counseling and education on behalf of patients in Ghana as they undergo breast cancer treatment. Age and monthly income of patients were statistically significant in predicting the anxiety and depression among the patients. The study's implications will lead to positive change when all stakeholders take on the responsibility of implementing measures to promote coping strategies for breast cancer patients in Ghana.
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Konan, Emma Roselyne Mrs. "Epidemiology of Adiposity in Childbearing Ghanaian Women." Digital Archive @ GSU, 2010. http://digitalarchive.gsu.edu/iph_theses/138.
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ABSTRACT BACKGROUND: The prevalence of adiposity (overweight and obesity) is increasing in among Ghanaian women. The disparity between urban and rural Ghanaian women in adiposity is seldom described due to data paucity. The purpose of this study was to provide a comparative analysis between urban and rural women in regards to the socio-demographic factors associated with adiposity. METHODS: The analyses used cross-sectional data from the Ghana Demographic Health Survey involving child bearing women ages14 to 49 years old. The eligible population comprised 4848 non-pregnant women (2023 from urban and 2825 from rural areas). Residence-specific (urban versus rural) associations between selected independent variables and adiposity were quantified using odds ratios from univariate and multivariate logistic regression analyses. Stepwise logistic regression analyses were used to describe the variables that were best predictors of adiposity. RESULTS: The overall crude prevalence of overweight (25.0-29.9 kg/m2) and obesity (≥30kg/m2) were 40% and 18% in urban and rural areas, respectively. There was a positive statistically significant difference between urban and rural women with respect to the distribution of overweight as well as obese (p<.001). Result from the univariate models showed that among rural and urban resident women, older age, higher education, higher wealth, and lack of job was each associated with increased odds of overweight. Compared to Akan women, being of other ethnic group was associated with decreased odds of overweight in women of urban and rural settings. Lack of fruits consumption and Muslim religion were each associated with increased odds of overweight in women who live in rural settings. Consumption of less than 5 fruits in a day was associated with decreased odds of overweight in urban resident women. For urban and rural resident women, wealth index and age were the best predictors for overweight. Older age, higher education, higher weight index, lack of jobs and being other than Akan ethnicity were each associated with increased odds of obesity in urban and rural settings. Compared to married women, being unmarried was associated with increased odds of obesity in urban and rural women. Wealth index was the best predictor variable of obesity in urban women. older age, education, wealth index, having a job, and fruit consumptions were the best predictors of obesity in rural women. CONCLUSION: Adiposity was more prevalent in urban living women compare to women who reside in rural areas. This finding is critical for planning effective adiposity control in Ghana. Proving education for Ghana women may enhance their wealth and knowledge about adiposity.
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Dawson-Amoah, Catherine Gyamfua. "Determinants of HIV Stigma Among Healthcare Workers in Ghana." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/1531.
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HIV-related stigma and discrimination is a complex concept that affects HIV reduction interventions. HIV-related stigma occurs among healthcare providers resulting in reduction of quality of care of people living with HIV. Social psychological research into stigma reduction has led to the development of many stigma reduction interventions, but has not resolved the underlying problem. This study was designed to identify predictors of stigmatizing behavior among healthcare workers in Ghana using the social cognitive theory (SCT) for use in developing an evidence-based intervention. The study used a cross-sectional research design incorporating a preexisting survey, Measuring HIV Stigma and Discrimination Among Health Staff: Comprehensive Questionnaire. Survey data were analyzed using descriptive, multiple regression analysis and Pearson's coefficient to estimate the relationship between the dependent variable, HIV related stigmatizing behavior, and independent variables, personal attributes and environmental factors. The key findings from the analysis were that the personal attributes of healthcare workers predicted their stigmatizing behavior (R2= 0.674, p < 0.05). There was, however, no significant relationship between environmental factors and stigmatizing behavior and between personal attributes and environmental factors. The social change implications may be to reduce stigma among healthcare workers toward people living with HIV and in turn increase the willingness of healthcare workers to engage with people living with HIV and provide quality service to them.
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Iacovelli, Gianpiero. "The Ideology of Mental Illness in Ghana : A Discourse Analysis of Mental Health Laws (1972-2012)." Thesis, Högskolan Dalarna, Afrikanska studier, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:du-28168.
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In 2012, Ghanaian government promulgated a new mental health law aimed at setting up a community-based health care system in order to solve several problems that are affecting mental health facilities and people with mental disorders. The new law was also thought to overcome the limitations of the previous law, which was promulgated in 1972. This study provides an analysis of the mental health laws promulgated by the government of Ghana from 1972 to 2012. Through the methodological tools offered by Critical Discourse Analysis (CDA), the aim of the thesis is to trace the ideological background of mental health laws and its changes over time. The analysis is particularly focused on themes such as the issue of public safety, the construction of the “mentally ill subject” and the conceptualisation of mental illness in the legal texts.
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Bailey, Claire Elizabeth. "Three papers on side effects and modern contraceptive use among women in Ghana." Thesis, University of Southampton, 2009. https://eprints.soton.ac.uk/166579/.
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This thesis investigates the issue of side effects and how they may act as a barrier to the use of modern contraceptive methods among women in Ghana. Three papers are presented each addressing the issue using different sources of data and different methodologies. The disparate nature of the data sources and techniques used provides each paper with its own perspective on the research question and each paper gives a unique insight into the topic. The aim of the first paper is to use a qualitative focus group methodology to explore in-depth the way individuals perceive information about family planning. The study seeks to better define what is meant by the term fear of side effect in this particular social context and to determine on what information and from what sources is this fear constructed. Overall the findings of this study show that fear of side effects does act as a significant barrier to the use of temporary methods and these fears result mainly from a large amount of negative information regarding side effects being passed through the social network. However the events being recounted cannot be dismissed as myth or rumour as they are most often based in real experiences. The second paper uses monthly data on contraceptive use and the experience of side effects from the calendar section of a longitudinal survey of women in Southern Ghana. Using life tables and a multi-level logistic discrete-time hazards model this study analyses contraceptive discontinuation and how it relates to the concurrent self-reported experience of side effects. The results show that experiencing side effects is associated with a higher probability of discontinuation of the method and that counselling from health workers is extremely important in minimizing discontinuation rates. The third paper uses a sub-sample of women who are not current contraceptive users from the 2003 GDHS. The study uses multiple logistic regression to determine the association between exposure to family planning information, through mass media and interpersonal channels, and the probability that a respondent will cite fear of side effects as their main reason for not intending to use a contraceptive method in the future. The results show that the only family planning communication variable which does have a significant effect is receiving a message from a health worker which increases the odds of fear of side effects being the main reason for not intending to use a method in the future. Overall the socio-economic characteristics of those not intending to use a method in the future due to a fear of side effects is more similar to current users than to those who are not intending to use in the future for other reasons.
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Mckeever, Samia. "Differentiating Geo-Spatiotemporal Aquatic Larval Habitats of Anopheles gambiae complex in Urban Agriculture and Urban Non-Agriculture Environments in Accra, Ghana." Scholar Commons, 2014. https://scholarcommons.usf.edu/etd/5423.
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To meet the rising food demands of communities in Accra,Ghana, urban agriculture has been popularized as a way to increase food security and improve nutrition (Donovan et al., 2012). Urban agriculture is defined as "the cultivation of crops at both the subsistence and commercial levels including the keeping of livestock in open spaces in urban areas (Adjaye, n.d.). In Accra, urban agriculture covers 1,091 hectares, employs over one thousand people, and supplies residents with 90% of its vegetables ("Accra Metropolitan", n.d.). Further, 60% of households in Accra participate in backyard farming ("Accra Metropolitan", n.d.). Although urban agriculture provides many benefits for communities in Accra, it has been linked to the creation of suitable habitats for Anopheles gambiae complex larvae.
In Accra, a spatio-temporal distribution of An. gambiae complex larvae and larvae habitats has not been established. A larval study in two urban agriculture and two non-urban agriculture sites was conducted in the months of May, July, August, and September 2014. When combined together, 3,807 An. gambiae complex larvae were collected from the urban agriculture sites of Korle Bu and Opeibea over the period of the study. When combining the urban non-agriculture sites of Madina and Ashaiman, 2,484 An. gambiae complex larvae were collected over the same period. The results of this study in Accra show that Korle Bu, an urban agriculture site, was the most productive site, with 2,604 An. gambiae complex larvae collected for the months of May, July, August, and September. July was the most productive month for Korle Bu, with 1,653 An. gambiae complex larvae collected. Further investigations of An. gambiae complex larval habitats are necessary to better understand malaria transmission attributes unique to Accra, Ghana.
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Mensah, Kofi Akohene. "An exploration of evaluation approaches for community based interventions for people living with HIV (PLHIV) with results applied to the ‘HOPE’ programme in Ghana." Thesis, University of Glasgow, 2011. http://theses.gla.ac.uk/2665/.
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Background: The increase in the number of people living with HIV (PLHIV), especially in sub-Saharan Africa, is a major public health concern. To date, most attention has been paid to prevention strategies and clinical trials of therapy. In comparison, there have been very few studies of care and support programmes. The ‘HOPE’ programme is a major community-based care and support programme in Ghana. ‘HOPE’ provides nutritional support, skills training for employment, health education and psychological support for PLHIV and for those orphaned through AIDS. Therefore, it was seen by policy makers in the country as desirable that it should be evaluated. A PhD scholarship was funded and the researcher presenting this thesis was appointed. Broad Aims The overall aim was to carry out an evaluation of the ‘HOPE’ programme in Ghana in order to make wider recommendations for evaluation of community-based interventions (CBIs) in Ghana and Africa generally. The timing was less than ideal as many of the major decisions about the intervention had already been made and baseline data had been collected. Therefore, the preliminary aim was to explore a range of possible evaluation methods so that the most suitable approach could be selected. Thereafter, a range of more specific aims, objectives and research questions was identified. Methods: A ‘mixed methods’ approach was adopted. The first component was a desk-based analysis of the literature on the various evaluation approaches that might, at least in theory, be applied to an HIV/AIDS intervention like ‘HOPE’. From this, a decision was made to evaluate ‘HOPE’ in terms of structure, process and outcome. The second component operationalised this decision by reviewing HOPE’s working documents and conducting two pieces of field work: a quantitative and a qualitative study. The quantitative study was a structured questionnaire administered to 200 PLHIV on the ‘HOPE’ programme. The qualitative study consisted of 14 interviews with stakeholders directly involved in the programme implementation and 8 focus group discussions with the programme beneficiaries. Results: The desk-based analysis achieved three main outcomes. First, it set out in a systematic manner the different approaches to evaluation that could in theory have been applied to ‘HOPE’. It identified strengths and weaknesses and the perspectives behind each approach. Second, it set out and then summarised a detailed description of the ‘HOPE’ programme and the national context in which it operated. Third, it set the above within the context of global literature on HIV, community-based interventions and nutritional support programmes. The analysis of the quantitative data showed that beneficiaries were being provided with soy-fortified wheat and vegetable fortified oil at the time of the evaluation. On average, beneficiaries gained weight (Mean difference in weight was 2kg with 95% CI (1.1, 2.9), p-value < 0.001) and increased Body Mass Index (BMI) (Mean difference in BMI was 0.8units with 95% CI (0.4, 1.2), P-value < 0.001). Over a third of the beneficiaries (37.5%) was currently unemployed and only one in five of the beneficiaries had been trained in a skill that might have been useful to find employment: this, despite skills training for all being a programme goal. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of a positive outcome. Qualitative components demonstrated perceived successes and challenges. Beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. They further indicated that the food was nutritious and contributed to their weight gain. Support groups have been sustained and membership increased. Some indicated that food should be more varied and some mentioned selling food to earn money to pay for their medications. Most of the beneficiaries indicated they were unemployed having lost their jobs as a result of stigmatisation. Only a few benefited from skills training leading to employment because of inadequate budgeting. Some who had been trained could not use their newly acquired skills because of lack of capital to start a business. To compound these weaknesses, most reported that they preferred petty trading to the skills offered. The monthly education and the training workshops generated hope, and improved knowledge of HIV/AIDS, promoted drug adherence and helped to reduce stigmatisation. The training of the PLHIV as peer educators is an effective method for HIV education and counselling since PLHIV listen to their peers more than health workers. Respondees predicted dissolution of the support groups when the programme ends. This is because they were not adequately involved in the decision making. Beneficiaries identified participation and cooperation as key prerequisites for sustainability but they also identified important weaknesses in ‘HOPE’ with respect to these criteria. Discussion: Despite the challenges presented by the timing and context of this study, it has been possible to carry out an evaluation that provides important learning. A mixed methods approach was appropriate and is likely to be useful in many similar evaluations. Beneficial outcomes were identified but these cannot be attributed, without qualification, to the intervention. Nonetheless, the findings indicated that participants were highly satisfied with the food support and monthly education. They were dissatisfied with the numbers trained in new skills and in other aspects of the skills training components. Also, the sustainability of the food component when the funding stops was a concern. However, the educational component could be sustained because peer educators could continue at very low cost. Most importantly, community involvement, using locally available resources, inter-sectoral collaboration and harnessing the motivation of local people were seen as key but underutilised ingredients. So, the results of the evaluation are encouraging but not conclusive. Nonetheless, care for people living with HIV is such an important problem that the desirability of conducting a cluster randomised controlled trial among a large number of support groups to assess the programme effectiveness on health, nutrition and economic status should be seriously considered despite the practical and ethical challenges implicit in such a recommendation.
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Tagoe, Ishmael. "The Ghana National School Feeding Program: Peoples' Perceptions about the Program's Impact on School Enrolment, Attendance and Completion." Bowling Green State University / OhioLINK, 2018. http://rave.ohiolink.edu/etdc/view?acc_num=bgsu1521682869298246.
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Owusu, Nicodemus Osei. "Malaria control policies and strategies in Ghana : the level of community participation in the intersectoral collaboration." Thesis, University of Southampton, 2011. https://eprints.soton.ac.uk/340008/.
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For more than a century now, malaria has been a major public health problem in Ghana which consequently has been one of the country’s sources of underdevelopment due to economic losses, high rate of morbidity and mortality. Faced with this problem, the last ten years has seen a commitment from the Ghanaian government to address the issue by establishing a policy that would transform the way the disease is prevented and controlled. The transformation of the management of the disease by the use of intersectoral collaboration strategy (ISC) was to ensure the inclusion of the grass root community members who were hitherto excluded from participating in policymaking process of the national malaria control programme (NMCP) activities. The idea was that by allowing the communities to participate, members would be empowered to have ownership of programme activities, could accept the challenges associated with the control of the disease, and above all contribute more effectively to the success of the policy goal of minimising the persistence of malaria in Ghana. However, over ten years now, no systematic study has been done to access the extent to which this policy goal has been rhetoric or a reality. This thesis therefore seeks to examine this vision by investigating the extent to which the community members are allowed by the health authorities to participate in this policy strategy. Drawing on the case studies in the rural and urban districts in Ghana, the practical reality of the degree of community participation in ISC has been explored. In addition, the roles played by the community members in malaria control programme activities were examined with the aim of understanding the importance of communities in malaria control efforts. Finally, the barriers to participation as well as the extent of the institutional involvement in ISC and its possibility to facilitate community participation have also been examined. Overall, the evidence from the study findings demonstrated that the established strategy of ISC has not significantly promoted community participation in the NMCP activities. While the communities were consulted on malaria issues, they were often excluded from the final decision-making on issues that needed to be acted upon. Consequently, the communities have no guarantee that their views will be considered during the final deliberation in which they have little or no part to play. In spite of this, the study found that through various ways, the community members had been playing a number of significant roles in the control activities. These roles included: supporting health staff in their outreach services, contributing in managing the environment, providing assistance in the monitoring and evaluation of malaria programmes and finally assisting victims to cope with the disease. The findings also indicated that without a number of barriers, certain existing contextual factors (e.g. good level of horizontal integration and political structures and social-cultural institutions) potentially could have contributed to the community participation. From the views of health officials, these barriers were the powers of central bureaucratic structures and lack of resources whilst the community members perceived poverty, lack of support from the local health authorities, the precarious nature of their livelihood and traditional culture as those factors that have undermined participation. These barriers were structural and as such tackling any one barrier in isolation was not likely to solve the malaria problem. Besides, no one government sector, on its own, through participation, could make it possible for the community members to have a full ownership of the control programme activities as well as develop a culture of malaria prevention and control. Thus in the context of the study sites, the study concluded that although there is no evidence to suggest that ISC has enhanced full community participation, the strategy should be commended. In reality, the finding indicated that through ISC strategy many sectors including the community have become more aware of malaria problem and communicate more to solve the problem together. In the light of this, the study finds joint action in the form of ISC across many government sectors as a potential solution if these barriers are to be dealt with in a more strategic way rather than a piecemeal manner. In conclusion, it has been argued that with such a complex problem like malaria, ISC with community participation in policy making process is both a necessary and sufficient condition in reducing malaria persistence in the study sites. The health sector must work collaboratively with other related sectors and it is with such collaborative efforts that can change the attitudes of the community members. Changes in behavioural attitudes are paramount if communities’ activities that affect the environment and promote breeding of mosquitoes are to be minimised. Thus with ISC strategy, what is further needed are: proper control planning that will ensure better coordination amongst sectors, adequate resources and behavioural change by the community members themselves. Each of these factors, I believe should not work in isolation, rather must work together otherwise malaria persistence in Ghana will not go away anytime soon.
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Dako-Gyeke, Phyllis. "Examining the Meaning-Making of Hiv/Aids Media Campaign Messages: A Feminist Ethnography in Ghana." Bowling Green, Ohio : Bowling Green State University, 2009. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=bgsu1250358866.
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Azagba-Nyako, Jolene. "Public health nutrition intervention to evaluate the nutritional impact of the Ghana School Feeding Programme in Lower Manya Krobo (LMK) district, and enhancing its effectiveness through a nutrition intervention." Thesis, University of Westminster, 2017. https://westminsterresearch.westminster.ac.uk/item/q5522/public-health-nutrition-intervention-to-evaluate-the-nutritional-impact-of-the-ghana-school-feeding-programme-in-lower-manya-krobo-lmk-district-and-enhancing-its-effectiveness-through-a-nutrition.
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School feeding interventions like many other donor dependent nutrition interventions in low-income countries have often been described to be ineffective or unsustainable because they are designed with donor specific nutritional interests, which often do not reflect the indigenous dietary preference and patterns of target populations. In Ghana, over half a million school children depend on the school meals as their main stable source of food for the day however there have been several reports of lack of nutritional impact of the due to the dependence on non-indigenous foods. The aim of this study was to develop school meals (SCm) for the Ghana School Feeding Programme (GSFP) in the Lower Manya Krobo District by employing local agricultural produce as food-to-food fortification. The study is based on the tailored functional food recipe concept that seeks to enhance the effectiveness of nutrition interventions by employing indigenous knowledge of food composition and food processing to improve micronutrients profile of local available foods without compromising palatability. Maize, sweet potatoes, soybeans, Moringa oleifera, palm nut oil, anchovies were processed using traditional methods. Each SCm was formulated using nutrition data from FAO West African-Food-Composition-Table to contain at least 40% DRI for protein. AOAC (2009) methods were used to analyse the nutritional content of the SCm and two sets of sensory tests were performed to determine acceptability. In all, five SCm were developed and per 100g of each SCm, carbohydrate (with crude fibre) and protein content ranged from 68.07g to 49.18g and 16.32g to 27.52g respectively whilst fat content ranged between 4.1g and 19.4g. Calcium content ranged from 284mg to 960mg whilst iron and zinc contents range between 7.17g to 11.17g and 0.97g to 1.59g respectively. In the sensory test, SCm coded FSM123, FSM101 and FSM579 had highest mean overall acceptability scores of 7.58±0.56, 7.74±0.81 and 7.71±0.70 respectively. The efficacy and effectiveness of the SCm were tested in a 6 months pilot nutrition n (180) and 9-month scale-up intervention (n=330) together with a control group and a GSFP group. After initial deworming and malaria screening, the intervention the GSFP group received the normal school meals, the control group received three portions of fruit as incentive the SCm group receive 15g weight bases of SCm meal together with nutritional education. The results showed that participants in the SCm treatment group had an average 3.24% increase in height (p≤0.05) and 13.08% increase in weight (p≤0.0.5) over the intervention periods. There was also a 17% decrease in anaemia prevalence compared 11% decrease in the control and 9% decrease in GSFP. The results illustrate that the application of indigenous knowledge, and innovation in of nutrition could be a plausible tool in enhancing the nutrient content of school meals. The SCm seems to provide some leverage and resilience against further malnutrition and when combined with deworming, malaria treatment buttressed with behaviour change communication provided greater nutritional impact on height and weight relative to the other groups in the study.
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Gu, Lily Y. "HIV-related stigma and autonomy-supportive healthcare climate predict linkage to HIV care in men who have sex with men in Ghana, West Africa." University of Cincinnati / OhioLINK, 2019. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1552377696238772.
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Vu, Thi Lan. "Determinants of utilization of insecticide-treated nets for malaria prevention among children under five years of age in Ghana: A secondary analysis of the National Malaria Indicator Survey Data 2016." Thesis, Uppsala universitet, Institutionen för kvinnors och barns hälsa, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-397980.
Full textAbstract:
Background: Insecticide-treated nets (ITNs) are one of the most effective prevention measures against malaria. Malaria is highly endemic in Ghana. The country implemented mass distribution campaigns of ITNs to cover 80% to 95% of the population but the rate of ITNs use among children under 5 years was 52%, which was lower than the universal coverage target of 100%. Objective: The objective of this study was to identify the socio-demographic factors associated with ITNs utilization among children under 5 years in Ghana. Methods: This was a secondary analysis from cross-sectional data of 3,029 children under five years obtained from Ghana Malaria Indicator Survey 2016. Logistic regression analysis was done to identify the determinants of ITNs utilization among children under 5 years in Ghana. Results: Size of the household, number of children ≤5 years old in the household, household wealth index, education level of mother, knowledge of mother on the protection of mosquito nets, place of residence, and region of residence were found to be significantly associated with ITNs utilization in children under 5 years. Conclusion: More interventions are needed to promote the use of ITNs to protect children against malaria. Interventions should focus on households with more than 7 members, households with more than 3 childrens ≤5 years, and on promoting girl’s education.
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Berg, Annika. "Den gränslösa hälsan : Signe och Axel Höjer, folkhälsan och expertisen." Doctoral thesis, Uppsala universitet, Institutionen för idé- och lärdomshistoria, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-100140.
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This dissertation investigates the mutual life project of Signe (1896-1988) and Axel Höjer (1890-1974), a married couple who were key actors in the construction of the Swedish welfare state. It emphasises the ways in which they went about asserting a special public health expertise in different contexts. As starting points I take the malleability of the concept folkhälsa (people’s health or population health) and the centrality of expertise in the governance of modern societies. Theoretical concepts such as gender, policy transfer, biopower and governmentality are central to the analysis. The dissertation includes three parts. The first part investigates how the Höjers agreed to coordinate their work and how they, with reference to ideas picked up in France and England at the end of World War I, attempted to reform mother and child health care in Sweden. Their strategies where rhetorical but also practical, using Hagalund outside Stockholm as their experimental ground. The second part investigates, firstly, how Axel Höjer, as General-Director of the Medical Board of Sweden (1935-52) asserted a sociomedical expertise, integrating the emerging social sciences and universalist views on the organisation of the welfare state into the realm of medicine, in order to launch ideas of a thorough reorganisation and expansion of the Swedish health care system. His focus was on preventive medicine and health care, with the complete physical, mental and social health of the whole population as an explicit goal. Secondly, it explores how Signe Höjer at the same time tried to launch ideas on health and wellbeing as a social politician and a public committee member. She also tried to define family policy as a specific policy area. However, despite her training as a nurse and a social worker, she was largely confined to asserting a particularly ”female” expertise, which made her position rather ambiguous in terms of authority. The third part investigates how the Höjers, in the 1950s and 60s, worked with international health, Axel mainly for the WHO in India and Ghana, Signe as a policy entrepreneur, primarily in the fields of childcare and family planning. My findings partly confirm theories that see development aid as an extension of domestic social policy, but they challenge the view of aid as a simple one-way process. I demonstrate how the Höjers at least tried to adapt their projects abroad to meet local circumstances, and also show how they brought lessons from the third world to a domestic public. In the latter case they did not primarily act as experts of Swedish-style social policy, but as experts on the developing countries and on development aid.
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Anafi, Patricia. "Understanding maternal health-care seeking behavior in low-income communities in Accra, Ghana." 2012. https://scholarworks.umass.edu/dissertations/AAI3518207.
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This study sought to examine health care decisions and choices that women make during pregnancy and childbirth in selected low-income and poor urban communities in Ghana. Specifically, it examined women's and community members' knowledge and perceptions about pregnancy and childbirth; existing forms of health care available to women during pregnancy and childbirth; and factors that influence preference for the type of health care that women use during pregnancy and childbirth. The study employed a two-phased data collection strategy involving in-depth interviews and focus group discussions to examine maternal health care seeking behavior of the target population. The findings revealed that the poor urban women have a wide range of perceptions and knowledge about pregnancy including knowledge about what constitutes a successful pregnancy and risk factors of pregnancy and childbirth complications. The study found that three major forms of health care exist for pregnant women: biomedical care; herbal-traditional birth attendant care; and spiritual care. While some women use or prefer to use either solely medical care or herbal-traditional birth attendant care for their pregnancy and delivery, others combine two or all the three forms of health care. Pregnant women seek traditional birth attendants (TBAs) and spiritual care for spiritual protection against death, due to affection and cultural attachment to TBAs, fears about medical care and health facilities, and due to cost of seeking medical care. Long waiting time and early reporting time at antenatal clinic were identified as partly limiting the use of medical care during pregnancy. Intimate partners of pregnant women were identified as negative normative influence since most of them do not support their wives during pregnancy. Quality and safety of care were the major reasons why pregnant mothers seek biomedical care other than other forms of care. However, majority of women who seek biomedical care do not seek timely antenatal care. Only 42 percent made their first antenatal visit in the first trimester. These findings have implications for policies and programs that are likely to help increase the use of skilled attendance and improve maternal health outcomes in the study population and other similar low-income urban communities in Ghana.
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Mottey, Barbara E. "Subnational Analysis of Birth Weight in Ghana using Bayesian Spatial Regression Models." 2021. https://scholarworks.umass.edu/masters_theses_2/1065.
Full textAbstract:
Child mortality in sub-Saharan Africa is reducing but the levels remain high with subnational within-country variations. Birth weight is a key predictor of child survival and monitoring birth weight outcomes, in particular, prevalence of low birth weights, is important for resource allocation to improve child survival outcomes.
Past research in sub-Saharan Africa has found that different individual-level factors are associated with birth weight including BMI of mother, sex of baby, educational level of mother, and wealth index of household. Some environmental factors are found to be associated with birth outcomes. However, past findings regarding the association of birth weight with household air pollution (HAP) resulting from cooking fuels are non-conclusive.
In this study, we analyze variability in birth weights subnationally for Ghana and assess its association with household air pollution resulting from cooking fuels, accounting for variation due to other factors including maternal and household predictors, as well as geographical location. The analysis was based on birth weights for 1310 births, obtained from data collected in 2014 in the Demographic and Health Survey (DHS).
We use Bayesian spatial regression models to estimate associations and capture spatial variation. Spatial variation was captured with a conditional autoregressive (CAR) model.
Based on various models, we do not find evidence to suggest that cooking fuel is associated with birth weight. After accounting for covariates, the average birth weights per district ranged from 2823g (95% CI: 2613g, 3171g) in Ketu district to 3243g (95% CI: 3083g, 3358g) in Ashanti Akim North district. Across Ghana, difference in birth weight attributable to district spatial effects range from -33g in Lawra district in Upper West region of Ghana to 11g in Ho in the Volta region.
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Segal, Tami. "Key vulnerabilities to HIV among men who have sex with men in Ghana." Thesis, 2016. https://hdl.handle.net/2144/19209.
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In Ghana, prevalence of HIV among MSM is significantly higher than that of the general population. Substance use and transactional sex in the urban settings of Ghana have been identified as risk behaviors that exacerbate chances of transmission for this vulnerable group. This thesis draws upon the findings of two companion studies that were conducted in Kumasi, Ghana by Boston University researchers in 2012. The objectives of the studies were to gain a deeper understanding of the behaviors and attitudes regarding substance use and transactional sex among younger and older MSM in Kumasi, Ghana. In the first study 99 MSM between the ages of 15 to 29 years old participated, of whom 55 attended focus group discussions (FGDs) and 44 participated in in-depth interviews (IDIs). In the second study 44 participants aged 30 years or older participated including 20 in IDIs and 24 in FGDs. Condom use was found to be inconsistent across all ages and most commonly attributed to reduced caution while drinking alcohol. Transactional sex was high among both young and older MSM, but younger MSM were more likely to be on the ‘receiving’ end of the transaction with the older men providing money and gifts. For both groups the internet was identified as a key method to contact prospective sexual partners suggesting the need to include social media in future HIV prevention interventions.
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Kofi, Janet. "Predictors of childhood stunting in Ghana : A cross-sectional survey of the association between stunting among children under age five and maternal bio-demographic and socioeconomic characteristics in Ghana 2014." Thesis, 2018. http://urn.kb.se/resolve?urn=urn:nbn:se:uu:diva-353865.
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Background: Stunting is impaired linear growth that occurs within the first 1000 days of life and continues later in life. It is associated with short and long term morbidity. This study aims to examine the association between stunting and maternal biodemographic and socioeconomic characteristics in children 0-59 months in Ghana. Methodology: The study is an analysis of a nationally representative sample of households, based on the socio-ecological framework. Data was sourced from the Demographic and Health Surveys (DHS) conducted in 2014. Logistic regression was used to analyze 2759 children aged 0-59 months. Results: The prevalence of stunting was 17.6%. Children 24-35 months had higher odds of stunting (OR=10.6 95% CI 5.18-21.8). Boys had higher odds than girls to be stunted (OR=1.62, 95% CI 1.21-2.17). There was an association between early initiation of breastfeeding, access to proper toilet facility, mothers’ level of education and ethnicity with stunting. Difficult access to healthcare was associated with high risk of stunting (OR=10.3, 95% CI, 1.38-76.8). Households with more than two U-5 children had higher odds of stunting (OR=1.61, 95% CI, 1.10-2.34). Conclusions: Stunting is a public health concern in Ghana. To address stunting, multisectorial interventions needs to be targeted at extending nutrition programmes to above 24 months. Nutrition interventions should prioritize early initiation of breastfeeding. Easy access to quality healthcare by strengthening the National Health Insurance Scheme (NHIS) should be promoted. Results also suggested that it is critical to invest in free education and scale up family planning programs.
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Akaligaung, John Akalpa. "Improving the quality of maternal and child health service delivery in resource-poor settings: case study of project fives alive! in Ghana." Thesis, 2015. https://hdl.handle.net/2144/16299.
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BACKGROUND: Quality improvement (QI) efforts in which providers from various health facilities, with support from coaches, work together to implement innovations for improving health care are rapidly spreading from high-income settings to resource-poor settings. However, limited research exists regarding the factors which drive teams to succeed or fail, spread, and sustain best practices. The purpose of this study was to understand the factors facilitating or inhibiting the performance of QI teams of maternal and child health (MCH) service delivery in resource-poor settings.
METHODS: A qualitative multi-site case study was conducted in northern Ghana to determine the views and beliefs of QI teams, coaches, and beneficiaries of Project Fives Alive (PFA) about the application of QI to MCH service delivery. Using key informant interviews, document review, and group interviews, the study elicited information about: 1) the factors that affect QI team success and failure when implementing QI methods designed to improve MCH service delivery; 2) the interplay of factors that facilitate or inhibit the spread of best practices among QI teams in northern Ghana; and 3) steps being taken by stakeholders to sustain these best practices. Grounded theory processes were used to identify themes from the data.
RESULTS: Testing of changes using Plan-Do-Study-Act (PDSA) cycles and adoption of a client-centered model to the delivery of services has helped teams to identify the felt needs of clients, resulting in perceived increased uptake of MCH services. Key contributory factors to successes were: availability and accessibility of midwives, training of QI teams, incentive packages for providers and clients, community support groups, and PFA partners. Key challenges inhibiting success were: staff turnover, inadequate supervision, cultural practices, and inadequate infrastructure. Some of the key factors that shaped successes have dissipated, threatening sustainability of QI efforts two years after PFA ended.
CONCLUSION: The presence of a midwife, providing leadership for organizing team members and implementing PDSA cycles, can facilitate success. Project staff support is important, but teams and coaches need space and time to drive the QI process independently and practice QI methods in ways that foster continuity beyond donor support.
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Norgbe, Gameli Kwame. "Factors responsible for the high default rate of tuberculosis patients paticipating in direct observed treatment short course." Thesis, 2008. http://hdl.handle.net/10500/2960.
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The purpose of this study was to describe the factors contributing to high default of DOTS implementation in the Kwaebibrim district of Ghana.
A quantitative, descriptive study was conducted to determine personal, health service, community and treatment factors contributing to high default of DOTS implementation in the district. Data collection was done using a structured questionnaire. Purposive sampling was done. The sample comprised of one hundred and thirty TB patients who were on DOTS implementation at the district chest clinic. The study highlighted TB patients’ knowledge about TB, socio-economic characteristics, organisation of care as well as community perceptions about the disease. The findings revealed that default to treatment is a complex behavioural issue involving multiple factors, an interaction of personal, social and health care factors as well as side effects of medication and duration of treatment. It is therefore recommended that interventions to prevent default of DOTS implementation should be designed with these factors in mind.
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Šanc, Filip. "Welfare state v rozvojových zemích: případová studie Botswany, Ghany a Indie." Master's thesis, 2013. http://www.nusl.cz/ntk/nusl-322964.
Full textAbstract:
This diploma thesis explores the emergence of the welfare state in developing countries, in particular shown on the example of Botswana, Ghana and India. The inquiry is focused on the period beginning in 1990, when the neoliberal paradigm was dominating, untill 2010. The recent years are in token of the shift from the neoliberalism to the post-neoliberalism characterized by a number of concepts, which are taking into account. The common feature of these concepts is the diversion from the narrow focus on GDP, as the only indicator of the growth, to the social dimension of the development. This shift is also being distinguished as a transition from the basic-needs concept to the rights-based approach. Therefore, the thesis explores, if these shifts are remarkable in the analyzed countries, eventually, if there are any divergences as compared to the theoretical concepts. To achieve this goal, a broader analysis of the welfare state was used, which involves social, health and education policy. Based on this analysis, the diploma thesis tries to classify the analyzed countries into the welfare state typology; eventually, in case such classification is impossible, it describes the weaknesses of this welfare state the typology. Powered by TCPDF (www.tcpdf.org)