A qualitative analysis of factors influencing the implementation of antiretroviral treatment adherence policy in Ghana: stakeholders perspective.

BACKGROUND: The Joint United Nations Programme on HIV/AIDS launched the 90-90-90 initiative. Failure to meet the target reflects the difficulties in successfully implementing HIV treatment policy. There are research gaps in exploring personal and external factors influencing HIV treatment in Ghana. To fill this gap, we explored individual and environmental (interpersonal, community and structural) factors influencing stakeholders' HIV treatment policy implementation in Ghana. METHODS: Fifteen qualitative semi-structured in-depth interviews were conducted among representatives in different management positions at hospitals, health directorates, the Ghana AIDS Commission, the National AIDS and STI control program, and the National Association of People Living with HIV. RESULTS: Using thematic analysis, the findings suggest that individual and environmental factors such as attitude towards policy, awareness of HIV treatment policy, training received on policy implementation, difficulties related to patient factors, alternate sources of HIV care, inefficient policy decision-making, monitoring and evaluation of HIV treatment policy, lack of HIV treatment policy implementation training, poor availability of logistics, policy and guidelines, infrastructure, organization of training, and staff availability may hinder successful HIV treatment policy implementation. CONCLUSION: Several individual and environmental (interpersonal, community and structural) factors seem to influence HIV treatment policy implementation. To ensure successful policy implementation stakeholders need to receive training on new policies, availability of sufficient supplies of material resources, inclusive decision-making, receive supportive monitoring of policy implementation, and oversight.

Every medicine is medicine; exploring inappropriate antibiotic use at the community level in rural Ghana.

BACKGROUND: Inappropriate antibiotic use is an important driver of antibiotic resistance. This study sought to explore inappropriate antibiotic use and confusing antibiotics with other medicines in Ghana using ethnomethodology research approach. METHODS: This was an explorative study involving 15 in-depth interviews among health professionals and private dispensers and eight focus group discussions among 55 community members. Qualitative data were coded using Nvivo 12, thematically analysed and presented as narratives with quotes to support the findings. RESULTS: Self-medication was common and antibiotics were used to treat specific diseases but respondents were not aware these were 'antibiotics'. Various antibiotics were used for indications that in principle do not require systemic antibiotics, like stomach ache and sores on the body. Antibiotics, in particular tetracycline and metronidazole, were poured into "akpeteshie" (local gin) to treat hernia and perceived stomach sores (stomach ulcer). These practices were copied/learnt from various sources like over-the-counter medicine sellers, family, friends, radio/television, drug peddlers, pharmacies and doctors. Medicines in capsules were referred to as 'topaye' or 'abombelt' in Twi (local dialect) and perceived to treat pain associated with diseases. Antibiotics in capsules were described with colours which appeared confusing as some capsules with different drugs in them have similar colours. CONCLUSION: Inappropriate antibiotic use were influenced by general lack of knowledge on antibiotics and identification of antibiotics by colours of capsules which leads to confusion and could lead to inappropriate antibiotic use. There is the need for public health education on appropriate antibiotic use and standardization of appearance of antibiotics and other drugs to optimize use.

Knowledge of antibiotic resistance and antibiotic prescription practices among prescribers in the Brong Ahafo Region of Ghana; a cross-sectional study.

BACKGROUND: Antibiotic resistance (ABR) has become a major public health challenge in most parts of the world including Ghana and is a major threat to gain in bacterial disease control. The role of prescribers in the control of antibiotics is identified as crucial in developing interventions to control ABR. To guide policy recommendations on ABR, a study was carried out among prescribers to identify gaps in their knowledge of ABR and to document their prescription practices. METHOD: A cross-sectional survey was conducted among prescribers from both public and private facilities in the Brong Ahafo Region of Ghana using both quantitative and qualitative methods in 2014. RESULTS: Three hundred and seventy nine prescribers participated in the quantitative study and a subset of 33 participated in in-depth interviews. Majority (50.0%) of the prescribers interviewed were nurses. Most (51.0%) of the prescribers were located in hospitals. Knowledge of ABR was high among all the prescribers. About 80.0% percent of all prescribers agreed that the antibiotics that are currently used could lose its efficacy in future. There is no singular formal source of information on antibiotic resistance. The prescribers held a strong perception that antibiotic resistance is imminent though their knowledge on various resistant bacterial strains was limited. Prescribers attributed ABR burden to factors such as poor prescription practices and limited ABR control measures. The prescription practices of the prescribers vary but were mostly inappropriate among the lower cadre. CONCLUSION: The knowledge of ABR is high among prescribers. There is however a gap in the knowledge and perception of optimal antibiotic prescription practices among prescribers. There is the need for a formal source of information on ABR to support prescriber's antibiotic prescription practices.

A qualitative analysis of factors influencing health-seeking behavior of people living with HIV, hypertension and diabetes in an urban area of Ghana.

Non-communicable diseases are rising globally and lower-middle-income countries are now facing a double-burden of communicable and non-communicable diseases like hypertension and diabetes. Patients with HIV/AIDS are at increased risk of developing hypertension and diabetes. Understanding how this double-burden influences persons living with HIV health-seeking behavior (HSB) is critical to identifying successful interventions and policies. To explore the factors that influence the health-seeking behavior of HIV patients with hypertension and diabetes in an urban setting of Ghana, we undertook a qualitative study consisting of sixteen in-depth interviews (five healthcare providers [HCP] and eleven patients); all recruited from Antiretroviral Therapy (ART) clinics in the Techiman South Municipality of Ghana. Interview questions were designed to explore cognitive, affective, social, and environmental factors that influence an individual's decision-making process and behavior. All interviews were audio-recorded, transcribed, and analyzed thematically. Participants raised unique challenges while seeking treatment services for HIV, hypertension, and diabetes. Frequent appointments, increased pill burden, food restrictions, alternate sources of care (herbalist and pastors), and negative psychological wellbeing were some of the challenges noted for seeking treatment services. Challenges with the health facility, including separate clinic days for comorbid conditions, high costs of medications and transportation, and long waiting hours were also cited as influencing health-seeking behavior. Results indicate greater challenges for HIV patients living with hypertension and diabetes in accessing treatment services. Understanding this is critical to removing barriers and making treatment more accessible. Further integration of treatment for hypertension and diabetes into HIV care is essential to ensuring patient engagement in continuous care.

Interventions to improve dispensing of antibiotics at the community level in low and middle income countries: a systematic review.

OBJECTIVES: Inappropriate antibiotic dispensing is one of the key drivers of antibiotic resistance. This review documents the effectiveness of interventions aimed at improving antibiotic dispensing practices at the community level by drug dispensers in low- and middle-income countries (LMIC). METHODS: We conducted a systematic search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science (11 November 2019). Studies were included if they reported data on the outcome measure: appropriate dispensing of medicine including antibiotics. The effectiveness of studies was assessed based on quantitative results reported in the studies included. RESULTS: A total of 1158 articles were screened. Thirteen studies from Asia (six), Africa (five) and South America (one) and one study from both Africa and Asia were included in this review. Nine (69.2%) studies reported significant effectiveness of interventions on all or more than 50% of antibiotic-related outcomes. Cochrane Effective Practice and Organization of Care interventions frequently applied were educational meetings (9/13), distribution of educational materials (7/13), educational outreach meetings (7/13), reminders (6/13), local consensus processes (6/13), distribution of supplies (6/14) and clinical practice guidelines (4/14), Nine studies reported on stakeholder involvement. CONCLUSION: This review shows that it is possible to improve antibiotic dispensing practices at the community level in LMIC. Stakeholders' involvement was key in the design and implementation of interventions.

Exploring the economic impact of inappropriate antibiotic use: the case of upper respiratory tract infections in Ghana.

BACKGROUND: Antibiotic consumption is increasing worldwide, particularly in low and middle-income countries (LMICs). Access to lifesaving antibiotics in LMICs is crucial while minimising inappropriate use. Studies assessing the economic impact of inappropriate antibiotic use in LMICs are lacking. We explored the economic impact of inappropriate antibiotic use using the example of upper respiratory tract infections (URIs) in Ghana, as part of the ABACUS (AntiBiotic ACcess and USe) project. METHODS: A top-down, retrospective economic impact analysis of inappropriate antibiotic use for URIs was conducted. Two inappropriate antibiotic use situations were considered: (1) URIs treated with antibiotics, against recommendations from clinical guidelines; and (2) URIs that should have been treated with antibiotics according to clinical guidelines, but were not. The analysis included data collected in Ghana during the ABACUS project (household surveys and exit-interviews among consumers buying antibiotics), scientific literature and stakeholder consultations. Included cost types related to health care seeking behaviour for URIs. Additionally, cost saving projections were computed based on potential effects of future interventions that improve antibiotic use. RESULTS: Health care costs related to inappropriate antibiotic use for URIs were estimated to be around 20 million (M) USD annually, including 18 M USD for situation 1 and 2 M USD for situation 2. Travel costs and lost income due to travel, together, were estimated to be around 44 M USD for situation 1 and 18 M USD for situation 2. Possible health care cost savings range from 2 to 12 M USD for situation 1 and from 0.2 to 1 M USD for situation 2. CONCLUSIONS: This study indicates that inappropriate antibiotic use leads to substantial economic costs in a LMIC setting that could have been prevented. We recommend investment in novel strategies to counter these unnecessary expenditures. As the projections indicate, this may result in considerable cost reductions. By tackling inappropriate use, progress can be made in combatting antibiotic resistance.

Stakeholders' perspectives on training over the counter medicine sellers and Community-based Health Planning and Services facilities to dispense antibiotics in Ghana.

BACKGROUND: Dispensing of antibiotics by over the counter medicine sellers (OTCMS) is a major driver of inappropriate use and resistance in low and middle income countries. Recent studies in Ghana revealed the need to consider training OTCMS and Community-based Health Planning and Services (CHPS)/health posts to dispense some antibiotics. Feasibility of training OTCMS and CHPS to dispense some antibiotics was explored in this study. METHODS: This was an explorative study involving 10 in-depth interviews (IDIs) among staff of Ghana health services (GHS), pharmacy council and the association of OTCMS at the district and regional levels. Next, findings were presented to the Ghana Antimicrobial Resistance (AMR) platform for further discussions at the national level. Five IDIs were also performed among selected members of the AMR platform as a follow-up on emerging issues. Data were thematically analysed and presented as narratives with quotes to support the findings. RESULTS: Two opposing views were found in our study. Leadership of OTCMS and GHS staff at the district health directorate supported the suggestion that OTCMS and CHPS should be trained to dispense specific antibiotics because they are already dispensing them. The leadership of OTCMS explained that some of their members are experienced and could be trained to improve their practices. In contrast, participants from pharmacy council, GHS in the region and national AMR platform generally alluded that OTCMS and CHPS should not be trained to dispense antibiotics because their level of education is inadequate. GHS personnel from the region further explained that training OTCMS could further compromise inappropriate antibiotic use in the context of already weak regulation enforcement. GHS and pharmacy council in the region rather suggested that OTCMS and CHPS should focus on public health education on disease prevention and appropriate antibiotic use. CONCLUSIONS: There is general lack of consensus among stakeholders on whether OTCMS and CHPS should be trained to dispense specific antibiotics. Further stakeholder engagement is required to carefully consider this suggestion as views on feasibility differ. Ministries of health and healthcare agencies in Ghana and LMIC should improve access to approved health services to improve antibiotic use in rural settings.

Community-based antibiotic access and use in six low-income and middle-income countries: a mixed-method approach.

BACKGROUND: Antimicrobial misuse is common in low-income and middle-income countries (LMICs), and this practice is a driver of antibiotic resistance. We compared community-based antibiotic access and use practices across communities in LMICs to identify contextually specific targets for interventions to improve antibiotic use practices. METHODS: We did quantitative and qualitative assessments of antibiotic access and use in six LMICs across Africa (Mozambique, Ghana, and South Africa) and Asia (Bangladesh, Vietnam, and Thailand) over a 2·5-year study period (July 1, 2016-Dec 31, 2018). We did quantitative assessments of community antibiotic access and use through supplier mapping, customer exit interviews, and household surveys. These quantitative assessments were triangulated with qualitative drug supplier and consumer interviews and discussions. FINDINGS: Vietnam and Bangladesh had the largest proportions of non-licensed antibiotic dispensing points. For mild illness, drug stores were the most common point of contact when seeking antibiotics in most countries, except South Africa and Mozambique, where public facilities were most common. Self-medication with antibiotics was found to be widespread in Vietnam (55·2% of antibiotics dispensed without prescription), Bangladesh (45·7%), and Ghana (36·1%), but less so in Mozambique (8·0%), South Africa (1·2%), and Thailand (3·9%). Self-medication was considered to be less time consuming, cheaper, and overall, more convenient than accessing them through health-care facilities. Factors determining where treatment was sought often involved relevant policies, trust in the supplier and the drug, disease severity, and whether the antibiotic was intended for a child. Confusion regarding how to identify oral antibiotics was revealed in both Africa and Asia. INTERPRETATION: Contextual complexities and differences between countries with different incomes, policy frameworks, and cultural norms were revealed. These contextual differences render a single strategy inadequate and instead necessitate context-tailored, integrated intervention packages to improve antibiotic use in LMICs as part of global efforts to combat antibiotic resistance. FUNDING: Wellcome Trust and Volkswagen Foundation.

Volunteering for Health Services in the Middle Part of Ghana: In Whose Interest?

BACKGROUND: In many developing countries like Ghana, community volunteers assist in the provision of certain health services to rural and hard-to-reach communities. This study examined factors that influence the motivation and retention of community-based volunteers supporting with work on health-related activities at the community level in Ghana. METHODS: Using a sequential mixed-method design, a cross-sectional survey was carried out among 205 selected community-based volunteers in Kintampo North Municipality (KNM) and Kintampo South District (KSD) of Ghana between December, 2014 and February, 2015. Qualitative interviews, including 12 in-depth interviews (IDIs) among health workers and community opinion leaders and 2 focus group discussion (FGD) sessions with volunteers were conducted. RESULTS: Personal interest (32.7%) and community leaders' selection of volunteers (30.2%) were key initial reasons for volunteering. Monetary incentives such as allowance for extra duty (88.8%) and per diem (49.3%) and non-monetary incentives such as T-shirts/bags (45.4 %), food during training (52.7%), community recognition, social prestige and preferential treatment at health facilities were the facilitators of volunteers' retention. There was a weak evidence (P=.051) to suggest that per diem for their travels is a reason for volunteers' satisfaction. CONCLUSION: Community-based volunteers' motivation and retention were influenced by their personal interest in the form of recognition by community members and health workers, community leaders' selection and other nonmonetary incentives. Volunteers were motivated by extra-duty allowance but not per diems paid for accommodation and feeding when they travel. Organizations that engage community volunteers are encouraged to strengthen the selection of volunteers in collaboration with community leaders, and to provide both non-monetary and monetary incentives to motivate volunteers.

Ghana's Rural Liquefied Petroleum Gas Program Scale Up: A case study.

BACKGROUND: The Government of Ghana launched the Rural LPG (RLP) promotion program in 2013 as part of its efforts to reduce fuelwood consumption. The aim of the RLP is to contribute to Ghana's overarching goal to provide LPG access to 50% of Ghana's population by 2020. The RLP has not announced long-term program objectives. However, in the interim the RLP targeted a cumulative total of 170,000 LPG cookstoves to rural households by the end of 2017. As of November 2017, 149,500 rural households had received the LPG cook stoves. Our case study documents Ghana's experiences to date with LPG scale up. METHODS: We carried out a desktop review/document analysis of literature on the RLP. Each document was reviewed for information related to the elements of the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework as it pertained to LPG promotion and adoption. In-depth interviews were held among key stakeholders in Ghana. Previously collected data from a field evaluation of the RLP was also assessed. FINDINGS: Generally, our evaluation suggests that the current form of the RLP is not achieving its stated goal. Our evaluation of the RLP in five rural communities showed that about 58% of households had never refilled their LPG cylinders nine months after the initial delivery of a filled cylinder. Only 8% still used their LPG at 18 months post distribution. Cost and distance to LPG filling stations were the main reasons for low LPG use. Beneficiaries did not exclusively use their LPG even at the initial stages when all of them had LPG in their cylinders. Ghana is currently undergoing transitions in the LPG sector including a change from the current private cylinder ownership model to a cylinder recirculation model for the distribution of LPG. There was no evidence of a well-documented implementation framework for the RLP. CONCLUSION: Fuel cost, poor LPG access, and an inadequate implementation framework hinder the RLP implementation.

To sell or not to sell; the differences between regulatory and community demands regarding access to antibiotics in rural Ghana.

BACKGROUND: In Ghana, there is extensive over-the-counter dispensing of antibiotics, resulting in high levels of inappropriate use, and an increase in antibiotic resistance. Regulations prevent Licenced Chemical Sellers (LCS, Over-the-Counter Medicine Sellers) from selling antibiotics other than Cotrimoxazole. In practice, however, these sellers sell a variety of antibiotics. This paper aims to provide insight into the differences between regulatory and community demands on the sale of antibiotics, and to explore how these differences in demand could be resolved to facilitate safe and appropriate use of antibiotics in rural Ghana. METHODS: A total of 32 in-depth interviews were conducted in the Kintampo North and South Districts in Ghana; 16 among antibiotic suppliers, predominantly LCS, and 16 among community members. Six focus group discussions were also conducted among 40 community members. Data were coded using Nvivo 10 and thematically analyzed in line with study objectives. The results are presented as narratives with quotes to illustrate the findings. RESULTS: Generally, antibiotic suppliers were aware that regulations prevent LCS from selling antibiotics except Cotrimoxazole. However, LCS sell all types of antibiotics because of community demand, economic motivations of LCS, and the poor implementation of regulations that are intended to prevent them from selling these medications. Factors that influence community demand for antibiotics include previous knowledge of effectiveness of some antibiotics, delays in seeking care at health facilities, financial constraints, and distance to health facilities. LCS suggested that they should be trained and allowed to sell some types of antibiotics instead of being prevented completely from selling. Community members also suggested that Community-based Health Planning and Services (CHPS) compounds should be equipped to dispense antibiotics. CONCLUSION: The sale of antibiotics by LCS at the community level is influenced by both structural and individual contextual factors. There is a need to educate community members on the appropriate access and use of antibiotics in rural Ghana. In addition, rather than enforcing rules that go against practice, it may be more effective to regulate the sale of antibiotics by LCS and train them to make their dispensing more appropriate. CHPS compound could also be equipped to dispense some antibiotics to improve appropriate antibiotic access at the community level.

Experiences with the Mass Distribution of LPG Stoves in Rural Communities of Ghana.

Household air pollution (HAP) is a leading cause of morbidity and mortality worldwide. To limit HAP exposure and environmental degradation from biomass fuel use, the Government of Ghana promotes liquefied petroleum gas (LPG) use in rural Ghana via the Rural LPG program (RLP). We assessed the experiences of the RLP in 2015, 2 years after its launch. A mixed methods approach was used involving Focus Group Discussions (19) and in-depth interviews (25). In addition, a survey questionnaire was administered to elicit socio-demographic characteristics, household cooking practices and stove use patterns of 200 randomly selected respondents. At about 9 months after LPG acquisition, < 5% of LPG beneficiaries used their stoves. Some of the reasons ascribed to the low usage of the LPG cookstoves were financial constraints, distance to LPG filling point and fear of burns. Community members appreciate the convenience of using LPG. Our results underscore a need for innovative funding mechanisms contextualized within an overall economic empowerment of rural folks to encourage sustained LPG use. It emphasizes the need for innovative accessibility interventions. This could include establishing new LPG filling stations in RLP beneficiary districts to overcome the barriers to sustained LPG use.

Low level of Hepatitis B knowledge and awareness among pregnant women in the Kintampo North Municipality: implications for effective disease control.

BACKGROUND: Over 2 billion people are infected with Hepatitis B virus (HBV) and about 240 million are chronic carriers of the virus. Chronic HBV infection is an important cause of liver cancer. The infectivity of HBV is hundred times higher than the HIV virus yet it receives comparatively little attention in public health. The study assessed knowledge and awareness of HBV among pregnant women in the Kintampo Municipality of Ghana. METHODS: A cross-sectional survey was conducted among pregnant women attending antenatal clinic in two facilities between September 2010 and November 2010. We performed analysis to determine factors associated with hepatitis B awareness. RESULTS: Forty-one percent of the 504 women were aware of hepatitis B viral infection, 33.5% of the women were able to correctly mention the transmission routes of Hepatitis B. The radio was the most (42%) mentioned source of information on HBV and the least source of information were places of worship (2.7%).After adjusting for other factors, level of education; SSS/SHS and above OR=4.2, P<00.1, 95% CI (2.5, 7.0) and occupation (Civil servant/Student); OR= 3.8, P00.1, 95% CI (1.7, 8.5) were the important predictors of Hepatitis B awareness. CONCLUSION: There is a low level of knowledge and awareness of HBV among pregnant women in this municipality. This could potentially hamper effective HBV prevention and control in Ghana. Education on hepatitis B need to be included in health promotion activities. FUNDING: The study was funded by KHRC Director's small grant Initiative.