Burden Of Stroke In Ghana: Prevalence, Experience And Caregiving

Background: Stroke has been named as one of the public health priorities in sub-Saharan Africa (SSA) because of its impact on mortality, morbidity and quality of life. Despite this, there is limited population-based information on prevalence and correlates of stroke, and there is limited information on knowledge and experience of stroke from the perspectives of the stroke survivors and their caregivers in SSA. Objectives: This thesis examined the prevalence, correlates, knowledge and experience of stroke in Ghana. It drew on three main concepts and theories: Health Related Quality of Life; explanatory models, and; biographical theories (biographical disruption, biographical transformation, biographical flow and biographical reinforcement). These concepts and theories were subsumed under social determinants of health. Methodology: This study adopted a triangulation mixed method approach using both quantitative and qualitative data. The wave 1 data of the World Health Organization (WHO) Survey on Global Ageing and Adult Health (SAGE) (Ghana) was used for the quantitative data and the sample size was 4,279 Ghanaian adults aged 50 years and above. The SAGE data was used to examine stroke prevalence and correlates as well as Health Related Quality of Life (HRQoL) of stroke survivors. While binary logistic regression was used to determine the correlates of stroke, multiple linear regression was used to determine the predictors of HRQoL of stroke survivors. For the qualitative data, a total of 22 stroke survivors and 29 caregivers were purposively selected from Ga Mashie and Korle-Bu Teaching Hospital (Physiotherapy and Stroke Units), Accra. Individual semi-structured interviews were used to explore the knowledge and experience of stroke from the perspectives of the stroke survivors and their caregivers. Data were analysed using thematic approach with the aid of Atlas ti. vi Results: Stroke prevalence was 4.6% and the correlates of stroke were being never married, unemployed, and living with hypertension and diabetes. This study showed that the HRQoL of stroke survivors was low in the physical health (body-self), functional, psychological, social and environment domains. The predictors of HRQoL of the stroke survivors were: unemployment, lower wealth status and living with hypertension. Particularly, the HRQoL was lower for stroke survivors who were unemployed; those in the poorest wealth quintiles, and; those living with hypertension. Further, participants’ knowledge on stroke causal theories, complications and prevention was eclectic and their sources of knowledge were mostly based on lived experiences of the stroke survivors and post-diagnosis information from health professionals. The impact of stroke on the stroke survivors centered on seven broad interrelated themes: body-self disruption; disruption to economic; disruption to social relationships; disruption to family relationships; cognitive disruption; nutrition disruption, and; lifestyle disruption. On the other hand, the impact of stroke on the caregivers centered on seven broad categories: disruption to physical body; disruption to economic circumstances; disruption to social relationships; nutrition disruption; psychological disruption; lifestyle disruption, and; disruption to life circumstances. Conclusion: This study showed high stroke prevalence among Ghanaian adults and the health of the stroke survivors affected that of their caregivers. The participants’ illness actions indicate that dual use of pharmaceutical and herbal treatments are adequate for stroke management. Further, the impact of stroke on stroke survivors and their caregivers was multifaceted. This indicates that interventions need to adopt a combined patient-and caregiver-focused approach in stroke survivor rehabilitation by adopting the Innovative Care for Chronic Conditions Framework, developed by World Health Organization

Medical Dominance in Global Health Institutions as an Obstacle to Equity and Effectiveness; Comment on “Power Dynamics Among Health Professionals in Nigeria: A Case Study of the Global Fund Policy Process”

Medical professionals exercised structural and productive power in the Global Fund’s Country Coordinating Mechanism (CCM) in Nigeria, directly impacting the selection of approaches to HIV/AIDS care, as described in a case study by Lassa and colleagues. This research contributes to a robust scholarship on how biomedical power inhibits a holistic understanding of health and prevents the adoption of solutions that are socially grounded, multidisciplinary, and co-created with communities. We highlight Lassa and colleagues’ findings demonstrating the ‘long arm’ of global health institutions in country-level health policy choices, and reflect on how medical dominance within global institutions serves as a tool of control in ways that pervert incentives and undermine equity and effectiveness. We call for increased research and advocacy to surface these conduits of power and begin to loosen their hold in the global health policy agenda

Fixed-dose combination therapy-based protocol compared with free pill combination protocol: Results of a cluster randomized trial

Fixed-dose combination (FDC) therapy is recommended for hypertension management in Nigeria based on randomized trials at the individual level. This cluster-randomized trial evaluates effectiveness and safety of a treatment protocol that used two-drug FDC therapy as the second and third steps for hypertension control compared with a protocol that used free pill combinations. From January 2021 to June 2021, 60 primary healthcare centers in the Federal Capital Territory of Nigeria were randomized to a protocol using FDC therapy as second and third steps compared with a protocol that used the same medications in free pill combination therapy for these steps. Eligible patients were adults (≥18 years) with hypertension. The primary outcome was the odds of a patient being controlled at their last visit between baseline to 6-month follow-up in the FDC group compared to the free pill group. 4427 patients (mean [SD] age: 49.0 [12.4] years, 70.5% female) were registered with mean (SD) baseline systolic/diastolic blood pressure 155 (20.6)/96 (13.1) mm Hg. Baseline characteristics of groups were similar. After 6-months, hypertension control rate improved in the two treatment protocols, but there were no differences between the groups after adjustment (FDC = 53.9% versus free pill combination = 47.9%, cluster-adjusted p = .29). Adverse events were similarly low (\u3c1%) in both groups. Both protocols improved hypertension control rates at 6-months in comparison to baseline, though no differences were observed between groups. Further work is needed to determine if upfront FDC therapy is more effective and efficient to improve hypertension control rates

Improving stroke care in Ghana: a roundtable discussion with communities, healthcare providers, policymakers and civil society organisations

Even though there have been advances in medical research and technology for acute stroke care treatment and management globally, stroke mortality has remained high, with a higher burden in low- and middle-income countries (LMICs) such as Ghana. In Ghana, stroke mortality and disability rates are high, and research on post-stroke survival care is scarce. The available evidence suggests that Ghanaian stroke survivors and their caregivers seek treatment from pluralistic health care providers. However, no previous attempt has been made to bring them together to discuss issues around stroke care and rehabilitation. To address this challenge, researchers from the Institute of Advanced Studies, University College London, in collaboration with researchers from the African Centre of Excellence for Non-communicable diseases (ACE-NCDs), University of Ghana, organised a one-day roundtable to discuss issues around stroke care. The purpose of the roundtable was fourfold. First, to initiate discussion/collaborations among biomedical, ethnomedical and faith-based healthcare providers and stroke patients and their caregivers around stroke care. Second, to facilitate discussion on experiences with stroke care. Third, to understand the healthcare providers’, health systems’, and stroke survivors’ needs to enhance stroke care in Ghana. Finally, to define practical ways to improve stroke care in Ghana

Social capital is associated with improved subjective well-being of older adults with chronic non-communicable disease in six low- and middle-income countries

Background: Non-communicable diseases (NCDs) are increasingly contributing to the morbidity and mortality burden of low and-middle income countries (LMIC). Social capital, particularly participation has been considered as a possible protective factor in the prevention and management of chronic conditions. It is also largely shown to have a negative effect on the well-being of patients. The current discourse on the well-being of individuals with NCDs is however focused more on a comparison with those with no NCDs without considering the difference between individuals with one chronic condition versus those with multiple chronic conditions (MCC). Method and objective: We employed a multinomial logit model to examine the effect of social capital, particularly social participation, on the subjective well-being (SWB) of older adults with single chronic condition and MCC in six LMIC. Findings: Social capital was associated with increased subjective well-being of adults in all the six countries. The positive association between social capital and subjective well-being was higher for those with a single chronic condition than those with multiple chronic conditions in India and South Africa. Conversely, an increase in the likelihood of having higher subjective well-being as social capital increased was greater for those with multiple chronic conditions compared to those with a single chronic condition in Ghana. Discussion: The findings suggest that improving the social capital of older adults with chronic diseases could potentially improve their subjective well-being. This study, therefore, provides valuable insights into potential social determinants of subjective well-being of older adults with chronic diseases in six different countries undergoing transition. Additional research is needed to determine if these factors do in fact have causal effects on SWB in these populations

How chronic conditions are understood, experienced and managed within African communities in Europe, North America and Australia: a synthesis of qualitative studies

This review focuses on the lived experiences of chronic conditions among African communities in the Global North, focusing on established immigrant communities as well as recent immigrant, refugee, and asylum-seeking communities. We conducted a systematic and narrative synthesis of qualitative studies published from inception to 2022, following a search from nine databases—MEDLINE, EMBASE, PsycINFO, Web of Science, Social Science Citation Index, Academic Search Complete, CINAHL, SCOPUS and AMED. 39 articles reporting 32 qualitative studies were included in the synthesis. The studies were conducted in 10 countries (Australia, Canada, Denmark, France, Netherlands, Norway, Sweden, Switzerland, United Kingdom, and the United States) and focused on 748 participants from 27 African countries living with eight conditions: type 2 diabetes, hypertension, prostate cancer, sickle cell disease, chronic hepatitis, chronic pain, musculoskeletal orders and mental health conditions. The majority of participants believed chronic conditions to be lifelong, requiring complex interventions. Chronic illness impacted several domains of everyday life—physical, sexual, psycho-emotional, social, and economic. Participants managed their illness using biomedical management, traditional medical treatment and faith-based coping, in isolation or combination. In a number of studies, participants took ‘therapeutic journeys’–which involved navigating illness action at home and abroad, with the support of transnational therapy networks. Multi-level barriers to healthcare were reported across the majority of studies: these included individual (changing food habits), social (stigma) and structural (healthcare disparities). We outline methodological and interpretive limitations, such as limited engagement with multi-ethnic and intergenerational differences. However, the studies provide an important insights on a much-ignored area that intersects healthcare for African communities in the Global North and medical pluralism on the continent; they also raise important conceptual, methodological and policy challenges for national health programmes on healthcare disparities

Health system adaptions to improve care for people living with non-communicable diseases during COVID-19 in low-middle income countries: A scoping review

BACKGROUND: During the COVID-19 pandemic, access to health care for people living with non-communicable diseases (NCDs) has been significantly disrupted. Calls have been made to adapt health systems and innovate service delivery models to improve access to care. We identified and summarized the health systems adaptions and interventions implemented to improve NCD care and their potential impact on low- and middle-income countries (LMICs). METHODS: We comprehensively searched Medline/PubMed, Embase, CINAHL, Global Health, PsycINFO, Global Literature on coronavirus disease, and Web of Science for relevant literature published between January 2020 and December 2021. While we targeted articles written in English, we also included papers published in French with abstracts written in English. RESULTS: After screening 1313 records, we included 14 papers from six countries. We identified four unique health systems adaptations/interventions for restoring, maintaining, and ensuring continuity of care for people living with NCDs: telemedicine or teleconsultation strategies, NCD medicine drop-off points, decentralization of hypertension follow-up services and provision of free medication to peripheral health centers, and diabetic retinopathy screening with a handheld smartphone-based retinal camera. We found that the adaptations/interventions enhanced continuity of NCD care during the pandemic and helped bring health care closer to patients using technology and easing access to medicines and routine visits. Telephonic aftercare services appear to have saved a significant amount of patients' time and funds. Hypertensive patients recorded better blood pressure controls over the follow-up period. CONCLUSIONS: Although the identified measures and interventions for adapting health systems resulted in potential improvements in access to NCD care and better clinical outcomes, further exploration is needed to establish the feasibility of these adaptations/interventions in different settings given the importance of context in their successful implementation. Insights from such implementation studies are critical for ongoing health systems strengthening efforts to mitigate the impact of COVID-19 and future global health security threats for people living with NCDs

Stakeholder perspectives on the demand and supply factors driving substandard and falsified blood pressure lowering medications in Nigeria: A qualitative study

OBJECTIVES: Although substandard and falsified (SF) blood pressure (BP) lowering medications are a global problem, qualitative research exploring factors driving this in Nigeria has not been reported. This study provides information on factors driving demand for and supply of low-quality BP lowering medications in Nigeria and potential strategies to address these factors. METHODS: This was a cross-sectional qualitative study. Between August 2020 and September 2020, we conducted 11 in-depth interviews and 7 focus group discussions with administrators of health facilities, major manufacturers and distributors of BP lowering medications, pharmacists, drug regulators, patients and primary care physicians purposively sampled from the Federal Capital Territory, Nigeria. Data were analysed using directed content analysis, with the aid of Dedoose. RESULTS: We found that demand for SF BP lowering medications in Nigeria was driven by high out-of-pocket expenditure and stockouts of quality-assured BP lowering medications. Supply of low-quality BP lowering medications was driven by limited in-country manufacturing capacity, non-adherence to good manufacturing and distribution practices, under-resourced drug regulatory systems, ineffective healthcare facility operations, poor distribution practices, limited number of trained pharmacists and the COVID-19 pandemic which led to stockouts. Central medicine store procurement procedures, active pharmaceutical ingredient quality check and availability of trained pharmacists were existing strategies perceived to lower the risk of supply and demand of SF BP lowering medications. CONCLUSION: Our findings suggest that demand for and supply of SF BP lowering medications in Nigeria are driven by multi-level, interrelated factors. Multi-pronged strategies need to target stakeholders and systems involved in drug production, distribution, prescription, consumption, regulation and pricing

To vaccinate or not to vaccinate? Experiences of COVID-19 vaccine uptake among people living with non-communicable diseases in Ghana: A qualitative study.

Following the development of a vaccine for COVID-19, the expectation was instantaneous widespread distribution and uptake to halt further spread, severe illness and deaths from the virus. However, studies show very low uptake, especially in resource-poor settings, and little is documented about the drivers of vaccine uptake in populations classified as high-risk. In this study, we explored access and uptake of COVID-19 vaccines among people living with non-communicable diseases (PLWNCDs) in Ghana. A qualitative study using in-depth interviews and focus group discussions was conducted among adults (>18 years) PLWNCDs stratified by sex, age, and type of non-communicable diseases (NCDs) at the community level (non-users of the health service) and health facility levels. Purposive sampling was used to select eligible participants. Topic guides were used to facilitate the face-to-face in-depth interviews and focus group discussions. The interviews and discussions were all digitally audio recorded. All transcripts and field notes were thematically analysed. Overall, 62 participants were recruited for this study. Family members, friends/peers, health workers and media were identified as the main sources of information for COVID-19 vaccines. Several barriers that mediated access to the COVID-19 vaccines in Ghana were reported including mistrust of vaccine efficacy and fears of vaccine side-effects, long distance to and waiting hours at vaccination centres, shortages of vaccines at vaccination centres and non-prioritization of NCD patients for the vaccine. To improve uptake, intensified education and sensitization, house-to-house vaccination, expansion of vaccination centers and increased supply of vaccines were recommended by participants. Compared to studies elsewhere, misinformation and disinformation were not major causes of vaccine hesitancy. If policymakers can improve community-based vaccine delivery, reduce queues and waiting times, prioritize PLWNCDs and other vulnerable groups, and improve sensitization and communication-our findings suggest there will be major improvements in COVID-19 vaccine coverage in Ghana

Process evaluation of a double-blind randomized controlled trial to assess the efficacy and safety of a Quadruple Ultra-Low-Dose Treatment for Hypertension within a federally qualified health center network (QUARTET USA)

BACKGROUND: This convergent parallel-design mixed-methods process evaluation of the QUARTET USA (Quadruple Ultra-Low-Dose Treatment for Hypertension USA) clinical trial (NCT03640312) explores patient and health care professional perceptions about the use of low-dose quadruple therapy (LDQT) as a novel strategy for hypertension management. METHODS AND RESULTS: A survey of all 62 patients enrolled in the QUARTET USA trial was conducted. A subsample of 13 patients and 11 health care professionals, recruited via purposive sampling, took part in semistructured interviews. At enrollment, 68% of participants (mean [SD] age, 51.7 [11.5] years; 56% self-identified as Hispanic: Mexican ethnicity, 16% as Hispanic: other ethnicity, 16% as Black race, 8% as White race, and 1.6% as South Asian race) reported that their current health depended on blood pressure medications, and 48% were concerned about blood pressure medications. At trial completion, 80% were satisfied with LDQT, 96% were certain the benefits of taking LDQT outweighed the disadvantages, and 96% reported that LDQT was convenient to take. Both patients and health care professionals found LDQT acceptable because it reduced patients\u27 perceived pill burden and facilitated medication adherence. Health care professionals stated that a perceived limitation of LDQT was the inability to titrate doses. Steps to facilitate LDQT implementation include introducing stepped-care combinations and treatment protocols, inclusion in clinical practice guidelines, and eliminating patient cost barriers. CONCLUSIONS: LDQT was an acceptable strategy for hypertension treatment among patients and health care professionals involved in the QUARTET USA clinical trial. Although LDQT was generally perceived as beneficial for maintaining patients\u27 blood pressure control and facilitating adherence, some clinicians perceived limitations in titration inflexibility, adverse effects, and costs. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03640312