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Background: The Ghana Community based Health Planning and Services (CHPS) strategy targets to bring health services to the doorsteps of clients in a manner that improves maternal and child health outcomes. In this strategy, referral is an important component but it is threatened in a rural context where transportation service is a problem. Few studies have examined perceptions of rural dwellers on transportation challenges in accessing maternal health care services within CHPS. Methods: Using the political ecology of health framework, this paper investigates transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system. Eight (8) focus group discussions involving males (n = 40) and females (n = 45) in rural communities in a CHPS zone in the Upper West Region of Ghana were conducted between September and December 2013. Results: Lack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services. Conclusion: These findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.
Ghana’s Upper West Region (UWR) is one of the poorest and least developed regions in the country. In the three regions in the north of Ghana, including the UWR, poverty is endemic. The UWR is the most affected, with 9 out of every 10 persons living on less than US $1.25 a day [24]. The widespread deprivation in the region together with less than desirable roads further challenges community health development. The UWR has a total population of 702,110, with 51.4 % female [25] and only 17.5 % of the total population characterized as urban, compared to national average of 51 % [25]. Endemic levels of poverty contribute to literacy rates much lower than the national average, especially for women [24]. The region has six hospitals and over 53,000 individuals to a doctor in 2013 [8], which is the worse in the country. Only 45.3 % of women in the UWR deliver in a health facility (the second lowest in the country) compared to well over 83 % in the Greater Accra Region, the national capital [24]. This study is concretized on perceptions of community members and community health workers. Although perceptions are subjective, they are shaped by experiences, social-cultural orientations and local environmental factors, thus remain relevant in providing an understanding to a local phenomenon and propounding strategies to fit local context [26, 27]. In addition, data gathering in a perception driven research requires a design that is flexible, non-sequential and allows the research to reshape while in progress, and qualitative research design allows just that [28, 29]. Focus Group Discussions were used to collect data between September and December 2013 in Dornye CHPS Zone in the Wa West District of the UWR of Ghana. FGDs were used, for the main reason that they have strength over other qualitative data collection methods (namely, individual interviews) in gathering perceptions and opinions of several respondents simultaneously and systematically [30] in informal and unstructured setting, which promotes participation and interaction [28, 31]. Further, focus groups were purposively drawn to create separate harmonious groups of males and females to enhance participation of group members and also ensure that gender undertones were captured [32]. Ultimately, FGDs are grounds for peer learning as debates and intense interaction on varied individual perceptions and opinions settle down to consensus group opinions and perceptions, serving as a form of education in several respects and truly becoming the prototype of society [33]. To ensure perspectives and opinions were diverse, and thematic saturation would be met, the study recruited males (n = 40) and females (n = 45) of ages between 18 and 70. This age category of participants would have had experiences and perspectives about the delivery of primary health care without a transport strategy. The large age range provided varied experiences on the subject. Community leaders and the CHO were briefed about the study and they subsequently informed particular community members based on their understanding that those were people who could adequately respond to the study questions. As participants arrived, the CHO gave identity numbers in the order of arrival, starting with the first to arrive. The first eleven (11) participants for each of the sexes formed the first group and the others formed the second group for discussion. Table 1 shows the characteristics of the study participants. Characteristics of study participants Data was collected using eight focus group discussions, four in each of the two study communities. All group discussions took place outside, in an open, under a tree in both communities. This made the setting familiar, unofficial and unstructured, a precept for participation. An experienced researcher in the team led discussions in Brefo and Waale/Dagaare, the main languages in the study area [28]. A checklist of questions mainly dealing with the relevance of transport in responding to referral or emergency cases, the effects of the absence of transport in the CHPS zone, and strategies for addressing transport issues in CHPS was used. Over all, the checklist only served as a guide, hence allowed related questions to be included and discussed. Discussions were lively, interactive and participatory, and lasted for 1 hour. With oral consent of participants, all FGDs were recorded verbatim (in Brefo and Dagaare/Waale) and later translated into English by a professional translator and transcribed. Transcribed scripts were read for emerging themes within the context of the study objectives. Reading and re-reading of transcribed scripts brought out categories and their related concepts. Codes were created from concepts and later compiled into a code scheme [34]. Text Analysis Markup System (TAMS) was used in organizing transcribed scripts, documenting categories, coding, and searching results. All transcribed scripts and audio recordings were uploaded onto TAMS for coding and processing. Line-by-line coding and re-coding was employed [35], and to ensure that similarities and differences across the eight focus group discussions were captured, the same coding scheme was applied to all transcripts. In effect, inductive and deductive coding was done [36, 37]. Notable emerging themes included “relevance of transport in CHPS”, “effects of absence of transport”, “coping strategies”, “strategies for sustainable transport” [36]. In ensuring consistency and credibility of data and the findings, considering the fact that qualitative research is largely interpretative and subjective [37], a number of strategies were used. Member checking was one of them. Transcribed scripts and initial emerging themes were sent back to participants and they confirmed two things; first, that the translation from local dialects into English and subsequent transcription were true representation of their discussions, and second that the initial meaning drawn from transcripts was the meaning to their discussions. The second strategy was source triangulation. Checks on transcribed scripts of the eight focus group discussion revealed that the emerging themes reached saturation. Generally, the same themes ran through the different discussion groups. Investigators triangulation was the third strategy used. Two different investigators coded the same portion of a transcribed script using TAMS and concluded on themes and concepts independently. They compared results, discussed and built consensus on the coding process [37]. In order to capture gender-influenced perspectives of the role of transport in delivery of primary health care, attention was paid to gender in the analysis of data. We were also very particular about the differences and similarities of perspectives on the strategies for sustainable transport in primary health from men and women, mainly due to its importance in policy planning and implementation. The ethical review committee of the University of Western, Ontario, Canada and the University of Development Studies, Wa Campus, Upper West Region, Ghana approved ethics for the research as part of a bigger maternal health research project in the Upper West Region of Ghana. The ethics guaranteed anonymity and confidentially of respondents and responses. It allowed for voluntary participation (entry and exit from the research) at any stage of the research process. Ethical consideration was communicated to research participants in a consent letter, which was endorsed before the start of the research.
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