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Background: Cardiovascular disease (CVD) is a growing burden in low-and middle-income countries. Ghana seeks to address this problem by task-shifting CVD diagnosis and management to nurses. The Community-Based Health Planning and Services (CHPS) initiative offers maternal and pediatric health care throughout Ghana but faces barriers to providing CVD care. We employed in-depth interviews to identify solutions to constraints in CVD care to develop a nurse-led CVD intervention in two districts of Ghana’s Upper East Region. Objective: This study sought to identify non–physician-led interventions for the screening and treatment of cardiovascular disease to incorporate into Ghana’s current primary health care structure. Methods: Using a qualitative descriptive design, we conducted 31 semistructured interviews of community health officers (CHOs) and supervising subdistrict officers (SDOs) at CHPS community facilities. Summative content analysis revealed the most common intervention ideas and endorsements by the participants. Findings: Providers endorsed three interventions: increasing community CVD knowledge and engagement, increasing nonphysician prescribing abilities, and ensuring provider access to medical and transportation equipment. Providers suggested community leaders and volunteers should convey CVD knowledge, marshaling established gathering practices to educate communities and formulate action plans. Providers requested lectures paired with experiential learning to improve their prescribing confidence. Providers recommended revising reimbursement and equipment procurement processes for expediting access to necessary supplies. Conclusions: Frontline CHPS primary care providers believe CVD care is feasible. They recommended a three-pronged intervention that combines community outreach, provider training, and logistical support, thereby expanding task-shifting beyond hypertension to include other CVD risk factors. This model could be replicable elsewhere.
A qualitative descriptive design structured this study. Qualitative descriptive designs are the most flexible of all qualitative approaches to research in that they seek to describe a phenomenon through the descriptive experiences of the participants [24,25,26]. In this case, we sought participant input about their experiences with a variety of interventions that could potentially adapt CHPS to facilitate CVD management. The Institutional Review Boards of the Icahn School of Medicine at Mount Sinai (IRB-16-01189) and the Navrongo Health Research Centre (IRB-250) approved this study. The study was conducted in the Kassena-Nankana West and Kassena-Nankana Municipal districts around the town of Navrongo in the Upper East Region of Ghana, localities where communities have been reached by research operations of the Navrongo Health Research Centre ever since a trial of vitamin A supplementation was launched in 1989 [27,28]. This area of Ghana is among the poorest in the country. Pervasive poverty and low educational attainment complicate the provision of effective primary health care [12,29]. Data on cardiovascular disease risk in this region include a rise in adult hypertension prevalence from 19.1% to 24.5% from 2008 to 2017 [6,30]. In the Navrongo area, the prevalence of overweight or obesity is 7.2% among men and 18.4% among women [31]; as of 2018, only 5.5% of the population of the Kassena-Nankana districts had elevated LDL cholesterol, but 60.3% had low HDL cholesterol [32]. Study participants were health care workers within CHCs in the Kassena-Nankana districts of Ghana’s Upper East Region. They were either CHOs, nurses provided with 18 months of training for conducting basic ambulatory, preventive, and promotional health care services in the community where their CHC is based, or SDOs, CHPS clinics’ administrative directors based in subdistrict health centers. SDOs often work as midwives at their clinics as well. Nurses and midwives are distinct professions in Ghana, although some are cross-trained for both roles. A semistructured interview guide (1) gauged participants’ beliefs and responses to previously determined barriers to providing CVD screening and treatment and (2) elicited participants’ attitudes and beliefs about interventions on the individual, CHC, and national level that will best allow for CHPS to screen for and treat CVD and its risk factors. Interviews were conducted on-site at CHCs during the months of June and July 2018 over a course of 6 weeks. Interviews were conducted in English—the language of nursing and midwifery education in Ghana—after obtaining written consent from each participant. Durations ranged from 24 to 63 minutes. This study was conducted as a joint endeavor of the Navrongo Health Research Centre (NHRC), Columbia University, and the Mount Sinai School of Medicine. D.J.H. planned the project protocol in collaboration with J.F.P. and A.R.O. Interviews were conducted by E.P.W. and K.L.G., both American medical students, with one additional interview conducted by E.D. E.D., D.A., and other NHRC staff supervised E.P.W. and K.L.G. at all interviews. This approach was intended to convey the research study to participants as a partnership cocreated and overseen by the NHRC, which has an extensive prior history of collaborative research with both the CHPS health program and the Navrongo community as a whole and employs chiefly local and national staff to underscore its mission as a Ghanaian health development institute. Moreover, NHRC staff arranged all interviews, answered any procedural or ethical questions about the research and its aims, and confirmed respondents’ facility in the English language. Both medical students also completed cultural competency training at their home institution prior to their arrival in Ghana. Sessions were audio recorded and then transcribed by the research team (E.P.W., K.L.G.). We then comparatively cross-checked each team member’s transcript to reconcile inconsistencies and ensure accuracy [33]. Data were deidentified upon completion of transcription. To analyze the interviews, we used summative content analysis to determine the interventions most often mentioned or described by participants, followed by an iterative generation of other themes and categories that emerged from the analysis. Summative content analysis specifically accounts for the frequency with which participants mention something, in this case interventions, within a specific context [34]. This had the added benefit of examining the data in its entirety before identifying specific interventions. We created codes for both barriers to CVD care and corresponding interventions through an iterative process wherein team members separately reviewed transcripts and met to compare identified codes for interventions. Participants would then determine which existing codes best represented the data and create new additional codes as needed to classify uncoded interventions. This ensured a shared understanding of each code’s and intervention’s meaning and increased the consistency of code application. After a consistent set of codes describing various interventions emerged, all transcripts were coded. NVivo was used for coding and analysis (NVivo 11, Melbourne, Australia) [35].
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