Protocol for a mixed-methods study to explore implementation outcomes of the Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) across 10 hospitals in Ghana.

BACKGROUND: Stroke survivors are at a substantially higher risk for adverse vascular events driven partly by poorly controlled vascular risk factors. Mobile health interventions supported by task shifting strategies have been feasible to test in small pilot trials in low-income settings to promote vascular risk reduction after stroke. However, real-world success and timely implementation of such interventions remain challenging, necessitating research to bridge the know-do gap and expedite improvements in stroke management. The Phone-based Interventions under Nurse Guidance after Stroke (PINGS-II) is a nurse-led mHealth intervention for blood pressure control among stroke survivors, currently being assessed for efficacy in a hybrid clinical trial across 10 hospitals in Ghana compared with usual care. This protocol aims to assess implementation outcomes such as feasibility, appropriateness, acceptability, fidelity, cost and implementation facilitators and barriers of the PINGS-II intervention. METHODS AND ANALYSIS: This study uses descriptive mixed methods. Qualitative data to be collected include in-depth interviews and FGDs with patients who had a stroke on the PINGS-II intervention, as well as key informant interviews with medical doctors and health policy actors (implementation context, barriers and facilitators). Data will be analysed by thematic analysis. Quantitative data sources include structured questionnaires for clinicians (feasibility, acceptability and appropriateness), and patients who had a stroke (fidelity and costs). Analysis will include summary statistics like means, medians, proportions and exploratory tests of association including χ2 analysis. ETHICS AND DISSEMINATION: Ethics approval was obtained from the Committee for Human Research Publication and Ethics at the Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. Voluntary written informed consent will be obtained from all participants. All the rights of the participants and ethical principles guiding scientific research shall be adhered to. Findings from the study will be presented in scientific conferences and published in a peer-reviewed scientific journal. A dissemination meeting will be held with relevant agencies of the Ghana Ministry of Health, clinicians, patient group representatives, and non-governmental organisations.

Community members and healthcare workers' priorities for the control and prevention of snakebite envenoming in Ghana.

INTRODUCTION: Snakebite is one of the most neglected tropical diseases. In Ghana, there has been a limited interest in snakebite envenoming research despite evidence of high human-snake conflicts. In an effort to meet the World Health Organisation's (WHO) 2030 snakebite targets, the need for research evidence to guide policy interventions is evident. However, in setting the research agenda, community and healthcare workers' priorities are rarely considered. METHODS: Three categories of focus groups were formed in the Ashanti and Upper West regions of Ghana, comprising of community members with and without a history of snakebite and healthcare workers who manage snakebite patients. Two separate focus group discussions were conducted with each group in each region. Using the thematic content analysis approach, the framework method was adopted for the data analysis. A predefined 15-item list of potential snakebite-associated difficulties and the WHO's 2030 snakebite strategic key activities were ranked in order of priority based on the participants' individual assessment. RESULTS: Both acute and chronic effects of snakebite such as bite site management, rehabilitation and mental health were prioritised by the community members. Health system challenges including training, local standard treatment protocols and clinical investigations on the efficacy of available antivenoms were identified as priorities by the healthcare workers. Notably, all the participant groups highlighted the need for research into the efficacy of traditional medicines and how to promote collaborative strategies between traditional and allopathic treatment practices. CONCLUSION: The prioritisation of chronic snakebite envenoming challenges by community members and how to live and cope with such conditions accentuate the lack of post-hospital treatment follow-ups for both mental and physical rehabilitation. To improve the quality of life of patients, it is essential to involve grassroots stakeholders in the process of developing and prioritising future research agenda.

Feasibility, acceptability, and appropriateness of a mobile health stroke intervention among Ghanaian health workers.

BACKGROUND: mHealth interventions can improve care delivery in settings with limited resources. The Phone-based Interventions under Nurse Guidance after Stroke (PINGS) is a nurse-led, mHealth-centered approach to blood pressure (BP) control among recent stroke survivors with hypertension in Ghana. It has 4 key components: (1) home blood pressure monitoring, (2) nurse-coordinated mhealth consults, (3) phone alerts as medication reminders, and (4) patient motivational messages delivered as interactive voice recordings. OBJECTIVE: To assess the feasibility, acceptability, and appropriateness for scale up of the PINGS intervention in Ghana, from the perspective of health workers. METHODS: Between July and August 2021, we deployed an online questionnaire describing the components of PINGS to a cross-section of health workers in Ghana. The questionnaire used an adaptation of psychometrically validated Likert scale measures to elicit agreement or disagreement with attributes of the intervention. The questionnaire was distributed online to approximately 4000 healthcare workers via email and social media platforms. A summary of descriptive statistics was obtained; summed composite scores were then calculated, dichotomized, and binary logistic regression performed using R programming software. RESULTS: Of 653 health workers who completed the survey, 57.2% were male; 73.2% clinicians; median age was 33 years (IQR 29, 37). Respondents' primary workplaces were public (64.4%), quasi-government (9.4%), and private, including mission-based (26.2%) facilities. PINGS was deemed feasible, acceptable, and appropriate by 93.9%, 94.8%, and 95.1% of respondents respectively. Clinical staff had higher odds of finding PINGS feasible (OR 4.10; C.I. 2.15, 8.0; p < 0.001), acceptable (OR 3.76, C.I. 1.87, 7.69; p < 0.001), or appropriate (OR 2.91, C.I. 1.41, 5.95; p = 0.004) compared to non-clinical staff. There was no statistically significant difference in the rating of each measure when analyzed by age, sex, years of health work experience, geographic location, type, or level of health facility. CONCLUSION: An overwhelming majority of health workers (particularly clinical staff) considered PINGS to be a feasible, acceptable, and appropriate for BP control among stroke survivors in Ghana.

What the snake leaves in its wake: Functional limitations and disabilities among snakebite victims in Ghanaian communities.

BACKGROUND: The estimated five million snakebites per year are an important health problem that mainly affect rural poor populations. The global goal is to halve both mortality and morbidity from this neglected tropical disease by 2030. Data on snakebite morbidity are sparse and mainly obtained from hospital records. METHODS: This community-based study was conducted among 379 rural residents with or without a history of snakebite in the Ashanti and Upper West regions of Ghana. All participants in the snakebite group were bitten at least six months before the day of survey. The World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0) and the Buruli Ulcer Functional Limitation Score were used to obtain patient-reported measure of functioning and disability. Long-term consequences were evaluated based on the severity of the symptoms at the time of the snakebite. FINDINGS: The median (IQR) time since the snakebite was 8.0 (3.5-16.5) years. The relative risk of disability was 1.54 (95% CI, 1.17-2.03) in the snakebite group compared to the community controls. Among patients with clinical symptoms suggesting envenoming at the time of bite, 35% had mild/moderate disabilities compared to 20% in the control group. The disability domains mainly affected by snakebite envenoming were cognition level, mobility, life activities and participation in society. A combination of the severity of symptoms at the time of the bite, age, gender and region of residence most accurately predicted the odds of having functional limitations and disabilities. CONCLUSION: The burden of snakebite in the community includes long-term disabilities of mild to moderate severity, which need to be considered when designing appropriate public health interventions. Estimating the total burden of snakebite is complicated by geographic differences in types of snakes and their clinical manifestations.