Factors Contributing To Delay In Key Populations Seeking Health Services: A Qualitative Study In Ghana By Abdulai Marijanatu Quaye Silas, Kenu Ernest, Baddoo A. Nyonuku, Chandi G. Margaretta, Danso A. Kenneth & Ayisi Addo Stephen Thursday 10th May, 2018

Outline Background Objective Methodology Results Conclusion Recommendations

Background-1 Men who have sex with men (MSM) and female sex workers (FSM) are key populations (KP) with higher risks of STI and HIV infection Delays and inappropriate health seeking behaviours by KPs for STI and HIV services may result in lower or adverse health outcomes Identifying factors that hinder health seeking among KPs will significantly help in programming

Study Objective General Objective To qualitatively assess client-level barriers and facilitators to HIV testing, enrolment, and retention in HIV care and treatment among FSW and MSM in the Greater Accra and Kumasi metropolitan areas Specific Objective To identify factors that contribute to delays in health seeking behaviours among KPs in two major cities in Ghana (Accra and Kumasi)

Methods 1/2 Study Type Qualitative method using descriptive phenomenology approach FGDs – 24 IDI - 90 Target population FSW MSM NGOs providing KP services GHS staff providing HIV Related services Sampling method Purposive method was used to recruit participants

Methods- 2/2 Recruitment and Eligibility Peer educators, NGO and GHS staff, and word-of-mouth through other study participants Potential KP participants were those who self-identified as either FSW or MSM, were 18 years or older and had consented to participate in the study Data collection and Analysis All interviews were conducted using an interview guide Recorded interviews was transcribed verbatim NVivo 11 was used to analyse the data

RESULTS

Background characteristics of the participants in the qualitative study FGDs ( N=198) Percentage(%) IDI (N=90)  Percentage(%) Sex Male 97 49.0 47 52.2 Female 101 51.0 43 47.8 Age   18- 29 129 65.2 37 41.1 28-39 51 25.8 26 28.9 38-49 15 7.6 11 12.2 48-59 3 1.5 6 6.7 Marital Status Single 160 80.8 53 58.9 Married 29 14.6 20 22.2 Cohabiting 0.0 Divorced 9 4.5 17 18.9 Education No education 2 2.2 Primary 39 19.7 7 7.8 JHS/SSS 91 46.0 36 40.0 Vocational Tertiary 50 25.3

Reasons given by KPs for delaying Health Seeking Reasons given by MSM Uncomfortable with a doctor who was caring for me Afraid and shy of myself Was asked to bring my partner which I couldn’t do Prefer herbal medicine Taking so many drugs is tiring Reasons given by FSW Lack of money Shy to disclose HIV status Afraid of stigmatization The illness makes you very weak Prefer to go to work Due to laziness Fear of being told of a problem Don’t want to miss a client Illness not serious They frown at you in the hospital Discrimination at the hospital

Reasons Given by Service Providers Lack of money to run some laboratory investigations e.g CD4,BUE&Cr Resort to herbal medications Resort to spiritual interventions Lack of time especially the FSW Distance Most feel healed after a few months of starting ARVs

Quotes from KPs on why they delay in seeking Health “The laboratory investigations like CD4 count, liver function test are too expensive ” – (MSM, Accra). “How they talk about it scares us so we don’t go for health Care” – (MSM, Kumasi). “Some of the nurses the moment they know you are MSM, they will start preaching you that how can a man sleep with a fellow man, are you not a Christian? – (MSM, Accra). “I delayed because of the side effect of the medication” – (FSW, Kumasi).

Quotes from KPs on why they delay in seeking Health “Many drink and smoke marijuana so they don’t remember HIV care enrolment” – FSW Kumasi “Sometimes you are spoken to harshly by the nurses so that put you off from going for treatment” MSM, Accra “Some delay in going for medical appointments because of long queues.”- FSW Kumasi “Some people believe that once you get the disease, you are going to die so there is no need for care”- (MSM, Kumasi).

Quotes from IDI Interviews from Service Providers “Because of the stigma attached to KP’s, most of them don’t want to come in at the clinical hours, they prefer to come in at odd hours and we overstay to handle such cases as they will normally come in after everyone is gone” (Service Provider- Kumasi) “Some of the clients after few months of starting ARVs, they feel they look better so they resort to spiritual remedies and are eventually brought back in critical conditions”(Service Provider- Accra) “I have an FSW client who is always defaulting her reason is simple I don’t want to miss a client when I visit the hospital”(Service Provider-NGO)

Conclusions and Recommendations Factors such as misconception about HIV transmission, stigma and discrimination by service providers, and financial constraints were identified as the major factors that cause delays in health seeking among FSW and MSM Recommendations It is important that GHS put in measures to ensure privacy and confidentiality in the delivery of HIV services at its facilities to enhance compliance to care by KPs The GHS should collaborate with policy makers so as to include the cost of laboratory investigations for PLHIV in the NHIS package.

Acknowledgements Ghana Health Service/NACP CDC MICDAK WAPCAS Dr Ernest Kenu Margaretta Gloria Chandi Mr. Daniel Kwablah Mrs. Comfort Asamoah Dr. Celia woodfill Trista Bingham Ijeoma Ugonna Mr. Silas Quaye Dr. Akosua Baddoo Ms. Marijanatu Abdulai Ms. Victoria Dafeamekpor Mr. Francis Frimpong