Ojo Temitope, Ryan Nessa, Birkemeier Joel, Appleton Noa, Ampomah Isaac, Glozah Franklin, Adongo Philip Baba, Adanu Richard, Boden-Albala Bernadette
Department of Social and Behavioral Sciences, New York University School of Global Public Health, New York, NY, USA.
Program in Public Health, Susan and Henry Samueli College of Health Sciences, University of California, Irvine, CA, USA.
Implement Sci Commun. 2020 Nov 17;1(1):104. doi: 10.1186/s43058-020-00084-8.
Stroke is a major cause of death in Ghana. Evidence-based interventions for stroke prevention have been successful in the US; however, in low- and middle-income countries (LMICs), such interventions are scarce. The "Discharge Education Strategies for Reduction of Vascular Events" (DESERVE) intervention led to a 10-mmHg reduction in systolic blood pressure (SBP) among Hispanic survivors of mild/moderate stroke and transient ischemic attack (TIA) at 1-year follow-up. Our objectives were to capture the perceptions of a diverse set of stakeholders in an urban community in Ghana regarding (1) challenges to optimal hypertension management and (2) facilitators and barriers to implementation of an evidence-based, skills-based educational tool for hypertension management in this context.
This exploratory study used purposive sampling to enroll diverse stakeholders in Accra (N = 38). To identify facilitators and barriers, we conducted three focus group discussions: one each with clinical nurses (n = 5), community health nurses (n = 20), and hypertensive adults (n = 10). To further examine structural barriers, we conducted three key informant interviews with medical leadership. All interviews were audio recorded and transcribed. Thematic analysis was carried out via deductive coding based on Proctor's implementation outcomes taxonomy, which conceptualizes constructs that shape implementation, such as acceptability, adoption, appropriateness, cost, and feasibility.
Findings highlight facilitators, such as a perceived fit (appropriateness) of the core intervention components across stakeholders. The transferable components of DESERVE include: (1) a focus on risk knowledge, medication adherence, and patient-physician communication, (2) facilitation by lay workers, (3) use of patient testimonials, (4) use of a spirituality framework, and (5) application of a community-based approach. We report potential barriers that suggest adaptations to increase appropriateness and feasibility. These include addressing spiritual etiology of disease, allaying mistrust of biomedical intervention, and tailoring for gender norms. Acceptability may be a challenge among individuals with hypertension, who perceive relative advantage of alternative therapies like herbalism. Key informant interviews highlight structural barriers (high opportunity costs) among physicians, who perceive they have neither time nor capacity to educate patients.
Findings further support the need for theory-driven, evidence-based interventions among hypertensive adults in urban, multiethnic Ghana. Findings will inform implementation strategies and future research.
中风是加纳的主要死因。在美国，基于证据的中风预防干预措施已取得成功；然而，在低收入和中等收入国家（LMICs），此类干预措施却很稀少。“降低血管事件出院教育策略”（DESERVE）干预措施使轻度/中度中风和短暂性脑缺血发作（TIA）的西班牙裔幸存者在1年随访时收缩压（SBP）降低了10mmHg。我们的目标是了解加纳一个城市社区中不同利益相关者对于（1）优化高血压管理面临的挑战，以及（2）在这种情况下实施基于证据、基于技能的高血压管理教育工具的促进因素和障碍的看法。
这项探索性研究采用目的抽样法，在阿克拉招募了不同的利益相关者（N = 38）。为了确定促进因素和障碍，我们进行了三次焦点小组讨论：分别与临床护士（n = 5）、社区卫生护士（n = 20）和高血压成年人（n = 10）各进行一次讨论。为了进一步研究结构性障碍，我们对医学领导层进行了三次关键信息访谈。所有访谈均进行了录音和转录。基于普罗克特的实施结果分类法，通过演绎编码进行主题分析，该分类法将影响实施的结构概念化，如可接受性、采用率、适宜性、成本和可行性。
研究结果突出了促进因素，例如核心干预组成部分在各利益相关者中被认为具有适应性（适宜性）。DESERVE的可转移组成部分包括：（1）关注风险知识、药物依从性和医患沟通，（2）由非专业人员提供便利，（3）使用患者推荐，（4）使用灵性框架，以及（5）应用基于社区的方法。我们报告了一些潜在障碍，这些障碍表明需要进行调整以提高适宜性和可行性。这些障碍包括解决疾病的精神病因、消除对生物医学干预的不信任以及根据性别规范进行调整。可接受性在高血压患者中可能是一个挑战，他们认为草药等替代疗法具有相对优势。关键信息访谈突出了医生中的结构性障碍（机会成本高），他们认为自己既没有时间也没有能力对患者进行教育。
研究结果进一步支持在多民族的加纳城市高血压成年人中开展理论驱动、基于证据的干预措施的必要性。研究结果将为实施策略和未来研究提供参考。
