Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals

Abstract

ObjectiveDespite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals’ views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings.DesignA qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes.SettingA multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana.ParticipantsA total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian.ResultsFour key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals.ConclusionBarriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.

The challenge to providing stroke care and rehabilitation in Malawi

“…This is against common trends in other countries, where admission to a stroke unit is recommended even in developing countries. 6 In addition to this seemingly structural challenge, this study found that the caregivers observed that hospital structures and facilities are not accessible to patients with stroke. As a step towards better care of patients with stroke, Malawi need to consider instituting stroke units with all facilities in place and accessible.…”

“…24 In a related qualitative study in Ghana among health professionals the authors also found that multidisciplinary stroke team which in most cases is physician-drives was inadequate, not inclusive, and an obstacle to effective patient care. 6 Additionally, although patients live geographically far away from a hospital, it should put in into its programming follow-up plans specific to patients with stroke. Liaison with district hospitals and health centers can also be critical as patients with stroke as well as their caregivers have a need for long-term care.…”

“…In line with a Ghanaian study finding, general nurses believed that the absence of a specific protocol or clinical guideline for acute stroke care was a key barrier. 6 We reasoned that the protocols set in place would enforce general understanding that different professionals are needed for holistic care for patients with stroke. Additionally, as utilization of physiotherapy during hospital admission has been associated with reduced length of hospital stay among patients with stroke 26 , there is a need for hospital physicians to recognize and engage physiotherapist as early as possible along stroke care continuum.…”

“…This study echoed the findings in Ghana where limited staff especially stroke specialists, shortage of medical equipment, such as blood pressure (BP) monitoring apparatus, cardio monitors, suction machines, adjustable hospital beds and inadequate space to facilitate patient care, were key barriers across the study sites. 6 There was a need for hospitals to be competitive through provision of equal opportunities for career advancement, lifelong learning, and flexible work schedules as well as develop policies that promote loyalty and retention 28 of the few who are already in the system.…”

“…Teams exist often in the absence of professional members, such as speech and language therapists and occupational therapists, and are poorly managed. 6 Resource constraint is another challenge that impedes robust stroke care in LMICs. For example, while some Malawian hospitals run radiological investigations, particularly CT scan and X-ray, this is often in absence of sophisticated diagnostic tools.…”