Adapting a nurse-led primary care initiative to cardiovascular disease control in Ghana: a qualitative study

Care for the cerebrovascular accident survivors: experiences of family caregivers

BACKGROUND

The role of family caregivers in the management of cerebrovascular accident survivors is invaluable. So far, there is a strong evidence affirming the effectiveness of family support for cerebrovascular accident survivors. Meanwhile, caring for cerebrovascular survivors can be labour and time intensive and pretty stressful for caregivers. The purpose of the study was to examine the lived experiences of family caregivers of cerebrovascular accident survivors in the Ho Municipality in the Volta Region of Ghana. This aims are to establish their caregivers' knowledge, preparedness, and impact of caregiving on the caregiver, and coping strategies caregivers adopted.

METHODS

Using a four-item (with 14 prompts) interview guide and descriptive phenomenological approach, we gathered and analysed data from 37 family caregivers in the Ho Municipality of Ghana.

RESULTS

We found that caregivers had limited knowledge about cerebrovascular disease-risk factors and were ill-prepared for their caregiving roles. Additionally, we found limited knowledge about coping strategies among the caregivers. We further report that some caregivers lost close relationships, and their jobs because of the caregiving, they also used fasting and prayer as coping strategies.

CONCLUSIONS

Caregivers suffered broken relationship, loss their jobs and incomes due to their caregiving roles. Moreover, some engaged in fasting and prayers, and alcohol use to cope with the stress associated with caring for the cerebrovascular accident survivors. We discussed the potential implications of our findings on the realisation of the Sustainable Development Goal 3.4. The aim of this goal is to reduce by 75% premature deaths due to cerebrovascular and other non-communicable diseases by 2030.

Role and knowledge of nurses in the management of non-communicable diseases in Africa: A scoping review

BACKGROUND

31.4 million people in low- and middle-income countries die from chronic diseases annually, particularly in Africa. To address this, strategies such as task-shifting from doctors to nurses have been proposed and have been endorsed by the World Health Organization as a potential solution; however, no comprehensive review exists describing the extent of nurse-led chronic disease management in Africa.

AIMS

This study aimed to provide a thorough description of the current roles of nurses in managing chronic diseases in Africa, identify their levels of knowledge, the challenges, and gaps they encounter in this endeavor.

METHODS

We performed a scoping review following the key points of the Cochrane Handbook, and two researchers independently realized each step. Searches were conducted using five databases: MEDLINE, PyscINFO, CINAHL, Web of Science, and Embase, between October 2021 and April 2023. A descriptive analysis of the included studies was conducted, and the quality of the studies was assessed using the Downs and Black Scale.

RESULTS

Our scoping review included 111 studies from 20 African countries, with South Africa, Nigeria, and Ghana being the most represented. Findings from the included studies revealed varying levels of knowledge. Nurses were found to be actively involved in managing common chronic diseases from diagnosis to treatment. Facilitating factors included comprehensive training, close supervision by physicians, utilization of decision trees, and mentorship. However, several barriers were identified, such as a shortage of nurses, lack of essential materials, and inadequate initial training.

CONCLUSION

There is significant potential for nurses to enhance the screening, diagnosis, and treatment of chronic diseases in Africa. Achieving this requires a combination of rigorous training and effective supervision, supported by robust policies. To address varying levels of knowledge, tailored training programs should be devised. Further research is warranted to establish the effectiveness of nurse-led interventions on population health outcomes.

Undiagnosed and uncontrolled hypertension in rural African adults: a scoping review protocol of primary health care interventions

INTRODUCTION

Non-communicable diseases cause 74% of global deaths, with cardiovascular diseases as the major contributor. Hypertension, a primary risk factor for cardiovascular disease, is highly prevalent in Africa. Diagnosis, treatment and control rates are notably limited in rural areas. This limitation results in increased risks of premature mortality and complications such as stroke due to socioeconomic, cultural and geographical challenges. Progress in African countries enhancing hypertension services through primary health care interventions exists. However, a comprehensive review of all primary health care interventions addressing undiagnosed and uncontrolled hypertension in rural African settings is lacking. This scoping review aims to categorise primary health care interventions targeting undiagnosed and uncontrolled hypertension in rural African adults. Intervention components will be mapped to the four stages outlined in the hypertension care cascade to develop a pilot intervention logic model for rural African adults with hypertension.

METHOD AND ANALYSIS

The scoping review protocol will adhere to the Joanna Briggs Institute methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. Studies considered for inclusion will include any intervention delivered by any healthcare provider in a rural African primary care setting targeting any stage of hypertension care. Eight databases will be searched without date restrictions, supplemented by grey literature and reference list searches. A two-stage screening process (title/abstract and full text) will determine evidence source eligibility. All eligible sources of evidence will be extracted, charted and evaluated using the Template for Intervention Description and Replication checklist. A pilot logic model categorising and mapping interventions to the four stages of the hypertension care cascade will be visually presented and analysed using narrative synthesis.

ETHICS AND DISSEMINATION

No primary data will be collected; therefore, ethics approval is not required. Findings will be disseminated to local health authorities in Ghana and other African Regions and through national and international conferences and publications in peer-reviewed journals.

Implementation of the Community-based Health Planning and Services (CHPS) in rural and urban Ghana: a history and systematic review of what works, for whom and why

Background

Despite renewed emphasis on strengthening primary health care globally, the sector remains under-resourced across sub-Saharan Africa. Community-based Health Planning and Services (CHPS) has been the foundation of Ghana's primary care system for over two decades using a combination of community-based health nurses, volunteers and community engagement to deliver universal access to basic curative care, health promotion and prevention. This review aimed to understand the impacts and implementation lessons of the CHPS programme.

Methods

We conducted a mixed-methods review in line with PRISMA guidance using a results-based convergent design where quantitative and qualitative findings are synthesized separately, then brought together in a final synthesis. Embase, Medline, PsycINFO, Scopus, and Web of Science were searched using pre-defined search terms. We included all primary studies of any design and used the RE-AIM framework to organize and present the findings to understand the different impacts and implementation lessons of the CHPS programme.

Results

N = 58 out of n = 117 full text studies retrieved met the inclusion criteria, of which n = 28 were quantitative, n = 27 were qualitative studies and n = 3 were mixed methods. The geographical spread of studies highlighted uneven distribution, with the majority conducted in the Upper East Region. The CHPS programme is built on a significant body of evidence and has been found effective in reducing under-5 mortality, particularly for the poorest and least educated, increasing use and acceptance of family planning and reduction in fertility. The presence of a CHPS zone in addition to a health facility resulted in increased odds of skilled birth attendant care by 56%. Factors influencing effective implementation included trust, community engagement and motivation of community nurses through salaries, career progression, training and respect. Particular challenges to implementation were found in remote rural and urban contexts.

Conclusions

The clear specification of CHPS combined with a conducive national policy environment has aided scale-up. Strengthened health financing strategies, review of service provision to prepare and respond to pandemics, prevalence of non-communicable diseases and adaptation to changing community contexts, particularly urbanization, are required for successful delivery and future scale-up of CHPS.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=214006, identifier: CRD42020214006.

Social and demographic correlates of cardiovascular mortality in the Kassena-Nankana districts of Ghana: a verbal post-mortem analysis

BACKGROUND

The burden of cardiovascular disease (CVD) in Ghana is rising, but details on its epidemiology are scarce. We sought to quantify mortality due to CVD in two districts in rural Ghana using verbal post-mortem (VPM) data.

METHODS

We conducted a proportional sub-hazards analysis of 10 232 deaths in the Kassena-Nankana East and West districts from 2005 to 2012, to determine adult mortality attributed to CVD over time. We stratified results by age, gender and socio-economic status (SES), and compared CVD mortality among SES and gender strata over time. A competing risk model estimated the cumulative effect of eliminating CVD from the area.

RESULTS

From 2005 to 2012, CVD mortality more than doubled overall, from 0.51 deaths for every 1000 person-years in 2005 to 1.08 per 1000 person-years in 2012. Mortality peaked in 2008 at 1.23 deaths per 1000 person-years. Increases were comparable in men (2.0) and women (2.3), but greater among the poorest residents (3.3) than the richest (1.3), and among persons aged 55-69 years (2.1) than those aged ≥70 years (1.8). By 2012, male and female CVD mortality was highest in middle-SES persons. We project that eliminating CVD would increase the number of individuals reaching age 73 years from 35% to 40%, adding 1.6 years of life expectancy.

CONCLUSIONS

The burden of CVD on overall mortality in the Upper East Region is substantial and markedly increasing. CVD mortality has especially increased in lower-income persons and persons in middle age. Further initiatives for the surveillance and control of CVD in these vulnerable populations are needed.

Constructing a Nurse-led Cardiovascular Disease Intervention in Rural Ghana: A Qualitative Analysis

Background

Cardiovascular disease (CVD) is a growing burden in low- and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana's Upper East Region.

Objective

This study sought to identify non-physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana's current primary health care structure.

Methods

Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants.

Findings

Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies.

Conclusions

Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.

Community burden of hypertension and treatment patterns: An in-depth age predictor analysis: (The Rural Community Risk of Non-Communicable Disease Study - Nyive Phase I)

BACKGROUND

This study aimed to describe the burden, treatment patterns and, age threshold for predicting hypertension among rural adults in Nyive in the Ho Municipality of the Volta Region, Ghana.

METHODS

A population-based cross-sectional study design was employed. A total of 417 adults aged 20 years and above were randomly selected from households within the Nyive community. The WHO STEPwise approach for non-communicable diseases risk factor surveillance (STEPS) instrument was used to obtain socio-demographic and clinical information including age, gender, educational background, marital status, and occupation as well as hypertension treatment information. Blood pressure was measured using standard methods. The risk of hypertension and the critical age at risk of hypertension was determined using binary logistic regression model and the receiver-operator characteristics (ROC) analysis.

RESULTS

The direct and indirect age-standardized hypertension prevalence was higher in males (562.58/487.34 per 1000 residents) compared to the females (489.42/402.36 per 1000 residents). The risk of hypertension among the study population increased by 4.4% (2.9%-5.9% at 95% CI) for one year increase in age while the critical age at risk of hypertension was >39 years among females and >35 years among males. About 64(46.72%) of the hypertensive participants were not on treatment whereas only 42(30.66%) had their blood pressure controlled.

CONCLUSION

Rural hypertension is high among adults in Nyive. The critical age at risk of hypertension was lower among males. The estimated annual increase of risk of hypertension was 4.7% for females and 3.1% for males. High levels of undiagnosed and non-treatment of hypertension and low levels of blood pressure control exist among the rural folks.

Prevalence, awareness and control of hypertension in Ghana: A systematic review and meta-analysis

BACKGROUND

Hypertension is a major health problem in Ghana, being a leading cause of admissions and deaths in the country. In the context of a changing food and health policy environment, we undertook a systematic review (PROSPERO registration number: CRD42020177174) and a meta-analysis of the prevalence of adult hypertension, and its awareness and control in Ghana.

METHODS

We searched major databases including PubMed, Embase as well as Google Scholar and online digital collections of public universities of Ghana to locate relevant published and unpublished community-based articles up till April 2020.

FINDINGS

Eighty-five articles involving 82,045 apparently-healthy subjects aged 15-100 years were analyzed. In individual studies, the prevalence of hypertension, defined in most cases as blood pressure ≥ 140/90 mmHg, ranged from 2.8% to 67.5%. The pooled prevalence from the meta-analysis was 27.0% (95% CI 24.0%-30.0%), being twice as high in the coastal (28%, 95% CI: 24.0%-31.0%) and middle geo-ecological belts (29%, 95% CI: 25.0%-33.0%) as in the northern belt (13%, 95% CI: 7.0%-21.0%). The prevalence was similar by sex, urban-rural residence or peer-review status of the included studies. It did not appear to vary over the study year period 1976-2019. Of the subjects with hypertension, only 35% (95% CI: 29.0%-41.0%) were aware of it, 22% (95% CI: 16.0%-29.0%) were on treatment and 6.0% (95% CI: 3.0%-10.0%) had their blood pressure controlled. Sensitivity analyses corroborated the robust estimates. There was, however, high heterogeneity (I2 = 98.7%) across the studies which was partly explained by prevalent obesity in the subjects.

CONCLUSION

More than one in four adults in Ghana have hypertension. This high prevalence has persisted for decades and is similar in rural and urban populations. With the low awareness and poor control of hypertension, greater investments in cardiovascular health are required if Ghana is to meet the global target for hypertension.