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MSc(Med)Population Based Field Epidemiology, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Introduction: In Africa, elderly adult mortality, just like many issues affecting the old has not been adequately addressed by research. This study explored the relationship between socioeconomic status (SES) and elderly adult mortality in an economically deprived region of rural Ghana. Methods: Data from the Navrongo DSS was used for the analysis. SES was determined from the asset data using principal component analysis. A total of 15030 adults aged over 60 years were included in the study, out of which 1315 died. We investigated the above relationship using Cox proportional hazards regression methods while controlling for other variables. Results: Socioeconomic status (SES) was found not to be a determinant of elderly mortality. Compared to the lowest SES quintile, the adjusted hazards ratios were, 0.94 (95%CI: 0.79–1.12) for second quintile, 0.91 (95%CI: 0.76–1.08) for third quintile, 0.89 (95%CI: 0.75–1.07) for fourth quintile and 1.02 (95%CI: 0.86–1.21) for the highest income quintile. However, living without a spouse [HR=1.98, 95%CI: 1.74–2.25], being male [HR=1.80, 95%CI: 1.59–2.04] and age [HR=1.05, 95%CI: 1.04– 1.05] were significant factors for elderly adult mortality. Conclusion: These results indicate that companionship, social and family ties in the health of the elderly adults are of more importance than the socioeconomic status of the household. Efforts should therefore be made to support the elderly, such as stipend for the elderly adults, especially those living alone; lowering the provision of free medical care in public hospitals to cover people over the age of 60 and not just 70 year olds and above as is currently done; encourage family care for the elderly relatives through provision of an elderly caretaker allowance among others.

Thesis advisor: Melissa M. Kelley / Thesis advisor: Lisa Sowle Cahill / Thesis (STL) — Boston College, 2016. / Submitted to: Boston College. School of Theology and Ministry. / Discipline: Sacred Theology.

MSc (Med), Population-Based Field Epidemiology, Faculty of Health Sciences, University of the Witwatersrand / Introduction: As people age, they become more vulnerable to ill‐health from acute and increasingly chronic diseases. This has elevated health care demand and utilisation in the elderly especially in the developed countries. In developing countries, ageing so far has not been a serious public health concern because of smaller number of older people in these countries. Recently however, the number of older adults in Sub‐Saharan Africa has increased rapidly, projected to stand at 130 million by 2050 from 30 million in 2000. This increase mirrors health related problems and has obvious public health implications. Thus, there is an urgent need to recognise and respond to health needs of the ageing populations in Africa. Objectives: To describe health care utilisation, health status and compare the proportions of adults aged 50+ years with moderate and poor health status to those with good health status. Another objective was to identify factors associated with health care utilisation among the elderly population in Kassena‐Nankana district, Ghana in 2007. Methods: Secondary analysis was performed on a cross‐sectional dataset collected between February and July 2007 through face‐to‐face interviews within the settings of the Navrongo DSS in Ghana. A total of 594 adults aged 50+ years participated in this study. The outcome variable was health care utilisation occurring in the last three years. Explanatory variables were grouped as predisposing, enabling and need‐related factors according to the behavioural model of health services utilisation. The predisposing variables were age, sex, marital status, ethnic background, education and smoking or use of smokeless tobacco. Occupation and financial position were included as enabling factors. Medical history of chronic conditions, self‐reported health status, difficulty with self‐care (e.g. bathing, washing, dressing etc), difficulty with picking up things in the last 30 days and cognitive impairment were grouped as need‐related factors. Logistic 382128 v univariate and multivariate regression analyses were conducted. STATA 10 statistical software was used to carry out this process. Results: The proportion of study participants reporting poor, moderate and good health status were 14.2%, 43.3% and 42.5% respectively. About one‐third (31%) of the study participants reported to have utilised health care services in the last 3 years. The following factors were identified as determinants of health care utilisation among the elderly rural Ghanaians: a medical history of at least one chronic condition (OR = 2.36; 95% CI = [1.49 – 3.75]; p < 0.001), self‐perceived health (OR = 2.00; 95% CI = [1.11 ‐ 3.59]; p = 0.021), age group (OR = 1.68; 95% CI = [1.07 ‐ 2.64]; p = 0.025), cognitive impairment (OR = 1.26; 95% CI = [1.02 – 1.56]; p = 0.032) and difficulty with picking up things in the last 30 days (OR = 0.76; 95% CI = [0.61 ‐ 0.96]; p = 0.021). Conclusion: Medical history of at least one chronic condition and poor perceived health status were the most pervasive determinants of health care utilisation. In addition, age group (60‐69 years), severe cognitive impairment and severe difficulty with picking up things in the last 30 days presented a significant influence on health care utilisation among the elderly population in rural Ghana. Recommendations: Provision of home‐based health care services could facilitate their accessibility for the elderly especially those with various difficulties. These factors could help health policy makers and health service providers identify and understand the situation of the elderly rural Ghanaians and consequently create conducive environment for providing appropriate health care services.

MSc (Med), Popualtion-Based Field Epidemiology, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand / Background Improving the health of the poor and reducing health inequalities between the poor and non-poor has become central goals of international organizations like the World Bank and WHO as well as, national governments in the contexts of their domestic policies and development assistance programmes. There are also unquantified and poorly understood inequalities in access to health services within and between various population groups. Little is known about the factors that determine these inequalities and the mechanisms through which they operate in various sub-groups. Objectives The aim of the study was first to describe under-five mortality trend according to wealth index; second to describe risk factors for under five mortality; and finally to investigate the relationship between socio-economic and demographic factors and under five mortality during the period 2001 to 2006. Methods The study involved all children born in 2001-2006. A total of 22,422 children younger than 5 years were found in 21,494 households yielding 36603.13 Person-Years Observed (PYOs) up to 31st December 2006. Household wealth index was constructed by use of Principal Component Analysis (PCA), as a proxy measure of each household SES. From this index households were categorized into five quintiles (i.e., poorest, poorer, poor, less poor and least poor). Life table estimates were used to estimate mortality rates per 1000 PYO for infants (0-1), childhood (1-5) and underfives children. Health inequality was measured by poorest to least poor mortality rate ratio and by computing mortality concentration indices. Trend test chi-square was used to determine significance in gradient of mortality rates across wealth index quintiles. Risk factors of child mortality were assessed by the use of Cox proportional hazard regression taking into account potential confounders. v Results The result indicates unexpected low mortality rate for infant (33.4 per 1,000 PYO, 95% CI (30.4 – 35.6)) and childhood (15.0 per 1,000 PYO, 95% CI (13.9 – 16.3)). Under-five mortality rate was 18.2 per 1,000 PYO (95% CI (75.6 – 108.0)). The poorest to least poor ratios were 1.1, 1.5 and 1.5 for infants, childhood, and under-five year olds respectively, indicating that children in the poorest quintile were more likely to die as compared to those in the least poor household. Computed values for concentration indices were negative (infant C= -0.02, children C= -0.09 and underfive C= -0.04) indicating a disproportionate concentration of under-five mortality among the poor. The mortality rates trend test chi-square across wealth index quintiles were significant for both childhood (P=0.004) and under-five year old children (P<0.005) but not for infants (P=0.134). In univariate Cox proportional hazard regression, children in the least poor households were shown to have a 35% reduced risks of dying as compared to children in the poorest category [crude H.R =0.65, P=0.001, 95% C.I (0.50 – 0.84)]. The results showed that for under five children, a boy is 1.15 times more likely to die as compared to a girl [crude H.R =1.14, P=0.038, 95% C.I (1.00 - 1.31)]. Second born had a 18% reduced risk of dying as compared to first born [crude H.R =0.82, P=0.048, 95% C.I (0.67 – 0.99)]. After controlling for potential confounders, the adjusted hazard ratio for wealth index decreased slightly. The estimated hazard for wealth index in the univariate was 0.65 while in the multivariate modeling the estimated hazard ratio is 0.60 in the first model. Conclusion The study shows that household socio-economic inequality is associated with underfive mortality in the Navrongo DSS area. The findings suggest that reductions in infant, childhood, and under five mortalities are mainly conditional in health and education interventions as well as socioeconomic position of households. The findings further call for more pragmatic strategies or approaches for reducing health inequalities. These could include reforms in the health sector to provide more equitable resource allocation. Improvement in the quality of the health services offered to the poor and redesigning interventions and their delivery to ensure they are more inclined to the poor.

In spite of the prevalence of rural-urban interactions in developing countries, much remains to be learnt about their welfare impacts. This thesis extends the discussion on rural-urban linkages by examining – for Ghana – two of the main forms of such interactions: migration and remittance flows. The study explores factors influencing migration and remittance flows, and also evaluates the impacts of these linkages on poverty and consumption welfare, using data from the 1998/99 Ghana Living Standards Survey. A key feature of the analyses is the construction of counterfactual scenarios and the application of a methodology that adjusts for selectivity bias.

This doctoral thesis analyses the internal migration of farmers from Northern Ghana to Brong Ahafo Region's agricultural frontier, theorizing this mobility as part of a wider ‘complex adaptive system' made up of interlinked social and environmental processes. It draws on original qualitative research conducted in three migrant ‘settler' communities in Brong Ahafo in 2014 in order to investigate local-level migration trends and histories, the relationship between in-migration and changing land tenure norms, and migrant farmers' perceptions of environmental change at their migration destinations. Each of these research themes provides an entry point for scrutinising the relationship between in-migration and the local ‘social-ecological system'. Finally, the thesis introduces a typology of livelihood trajectories among migrant tenant farmers in Brong Ahafo based on research findings at the three case study sites, which accounts for livelihood differentiation among migrants. This thesis thus makes an original contribution to the literature on the climate-migration nexus and to debates about rural development in Sub-Saharan Africa. In the case of the former, much of the current literature on ‘environmental migration' focuses on the extent to which environmental factors influence out-migration from communities of origin, and whether such migration can be thought of as a form of ‘adaptation' to environmental change. Debates about rural development, meanwhile, are increasingly preoccupied with understanding rural transformations. This thesis illustrates the need to consider how environmental conditions can affect migrant livelihoods at rural destinations, where livelihoods are often highly sensitive to environmental factors, and to account for how in-migration can serve as ‘feedback' which contributes to changing social and environmental conditions in such areas. Additionally, the stratified migrant livelihood trajectories encountered at my field sites show the diversity of migrants' agency, which affects their capacity to adapt to climatic and other shocks in situ as well as to provide support for kin in Northern Ghana.

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 1981. / MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH. / Bibliography: leaf [46]. / by Lynn Ann Chatman. / M.C.P.

A major vehicle for the decentralized implementation of education policies in Ghana is the district education office, the head of which is the district director of education. This study offers an understanding of the position of district directors of education (DDEs) and demonstrates the complex dynamics inherent in their work. It critically analyses the directors' rank and role as policy actors and their power to act. It also provides an informed view of how DDEs negotiate the challenges associated with the contexts within which they work. This study further examines the mechanisms for the DDE's identity construction and capacity to provide appropriate leadership and management. Adopting a social constructivist philosophical stance this research is framed in terms of narrative and case study. The data set comprises interviews with six DDEs studied as a single holistic case and a participant observation of a conference of directors. Additionally my personal experience as a district director provided deep insight complemented by a reflective research journal which documented my own biases, feelings and thoughts. The findings of the study suggest that policy formulation and implementation in Ghana does not seem to promote devolution of power from national policy actors to local-level actors in a manner that enables influence from DDEs. It illustrates that specific socio-cultural and organizational contexts have enormous influence on the professional identity formation of DDEs. The study concludes that an understanding of the complex contexts of the district director is critical for developing appropriate leadership and management practices. This study is pertinent to my own professional identity as an education administrator and a researcher. Fundamentally, this research has changed my perspectives on what it takes to be a district director and has enhanced my understanding of the research process. Its contribution to scholarship is the systematic re-examination of the district director position enabling a deeper understanding of the phenomenon. It is particularly relevant not only to my colleague directors, but also to senior education administrators in the GES and policy makers in the Ministry of Education.