COVID-19 testing: A qualitative study exploring enablers and barriers in the Greater Accra Region, Ghana

doi:10.21203/rs.3.rs-1495158/v1

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COVID-19 testing: A qualitative study exploring enablers and barriers in the Greater Accra Region, Ghana

https://doi.org/10.21203/rs.3.rs-1495158/v1

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Introduction: Despite the rolling out of vaccines, the importance of extensive testing along with effective tracing and treatment is still crucial to slowing transmission of the COVID-19 virus. However, testing barriers can be significant impediments to effective COVID-19 response. This study explored enablers and barriers to COVID-19 testing in the Greater Accra region of Ghana. We envision lessons learned from this study could serve as a roadmap to strengthen the current response to COVID-19 and preparedness for future outbreaks, particularly in low- and middle-income countries. Methods: A qualitative design was undertaken to explore the phenomenon. Data collection methods included in-depth interviews with key informants with a purposively selected sample of 20 participants. Interviews were conducted using flexible semi-structured interview guides. Depending on the participant's position and involvement in COVID-19 testing, the guides were modified, and key elements were drawn from a tailored version of the WHO Health System Framework incorporating the Essential Public Health Functions (EPHF). The interview findings were augmented by reviewing published literature. Results: Better health governance and political leadership, community participation, multisectoral collaboration, effective resource management and information systems were key enablers of COVID-19 testing. Findings also revealed a strong political willingness to committing financial resources to enhance testing. The primary barriers to testing were mainly COVID-19 infodemic, inadequacy of material resources to meet growing health needs, and lack of opportunities to have equal and easy access to testing services. Further, although human resources were adequate, they were unevenly distributed across settings. Conclusion: To effectively be prepared for COVID-19 testing and respond to future outbreaks, the following are recommended: there should be improved political commitments to ensure even distribution of all resources across the country; financial supports should be provided for the poor to protect them from the financial burden of paying for expensive testing services; improving community participation should be encouraged to address socio-cultural barriers to testing hesitancy. However, multilateral cooperation with diverse stakeholders beyond the scope of health will be essential in facilitating pandemic responses such as scaling up testing strategies

COVID-19 testing

barriers

facilitators

qualitative research

Ghana

The Coronavirus Disease 2019 (COVID-19) pandemic has dominated headlines worldwide since first reported in 2019. According to the World Health Organization (WHO), there have been 396 million confirmed cases of COVID-19, including 5.7 million deaths, and 10 billion vaccine doses have been administered as of 8 February 2022 [1]. Although vaccines are rolled out in many countries to help reduce the risk of contracting the virus and infecting others, extensive testing remains essential to slow the transmission [2]. Besides, COVID-19 testing could be a potentially less disruptive management strategy, particularly where vaccine access is limited [2]. Increasing testing capacity enables resource-poor countries experiencing slow rollout of vaccines due to poor supply chains to break disease transmission and reform the architecture for future pandemic preparedness efficiently and reform the architecture for future pandemic preparedness efficiently [3].

Several countries adopted strict measures at the beginning of the pandemic to contain the spread of the virus. Ghana, a lower-middle-income country in West Africa, with a population of about 30 million, recorded its first case on 12 March 2020 [4]. But even before that, the country had already implemented early preventive strategies such as the 3T approach (tracing, testing and treating) in response to the pandemic [4]. Efforts were geared towards the adoption of multisectoral actions with wide control measures to prevent, detect and contain the disease. The private sector, civil societies and faith-based organizations all play a key role in this regard. For example, through the private sector, the government is putting up a 100-bed hospital to be completed within six weeks for the isolation and treatment of COVID-19 patients [5–6]. Moreover, Ghana's longstanding efforts to strengthen Primary Health Care (PHC) through the Community-Based Health Planning and Services (CHPS) program, its National Health Insurance Scheme (NHIS) [7] altogether contributed to the success of extensive testing of which the WHO is even studying some of the techniques [8].

Ghana has one of the highest testing rates in sub-Saharan Africa [4, 9]. Comparing tests conducted as per the million population in sub-Saharan Africa, Ghana has made huge progress in testing a large number of the population [4, 9]. Its daily tests per million is 100, which is the second-largest test performed as of 2 March 2022 [4, 6, 9]. This might be the result of the President’s early policy decision to enhance the capacity to test and expand the numbers of testing, treatment and isolation centers [10]. Further, Ghana used the overarching contact tracing approach, which has now become a model in managing COVID-19 [10]. Although the approach worked well within the Ghanaian context, it has also been constrained by the issue of resource, infrastructure and COVID-19 infodemic.

Despite the importance of COVID-19 testing as cost-effective prevention, isolation and detective measure, there is very little literature, including some articles, commentaries and opinions exploring the effect of factors influencing the testing in the context. This study examines the facilitators and barriers to COVID-19 testing in Ghana. We envision findings could serve as a roadmap scale-up COVID-19 testing and improve future responses to the pandemic, especially in low-middle income countries. This study is part of a two-country study on identifying facilitators and barriers to scale-up COVID-19 testing in Bhutan [11] and Ghana.

Study design, sampling and data collection

A qualitative design was undertaken to explore the barriers and facilitators to scaling up COVID-19 testing implementation in Greater Accra, Ghana. It is the capital city of the country, with a population of about 2.6 million [12–13]. A purposive sampling approach was used to recruit 20 key informants for interviews from September to October 2021. Participants provided written consent before being interviewed. All interviews were conducted virtually through a Zoom platform by authors SH, SY. Study participants comprised policymakers, implementers, frontline workers, and community members. Refer Table 2 for the characteristics of interviewees. Interviews lasted between 40 and 60 minutes and were audio-recorded.

Interviews were conducted using flexible semi-structured interview guides. Depending on the participant's position and involvement in COVID-19 testing, the guides were modified, and key elements were drawn from the WHO Health System Framework incorporating the Essential Public Health Functions (EPHF) [14].

We stopped interviews when we realized no new information was emerging, i.e., when data saturation has been achieved. All researchers agreed on four general principles and concepts regarding data saturation; no new data, no new themes, no new coding, and the ability to replicate the study [15]. Researchers were confident that the collected data were sufficient, consistent, and qualified enough to meet the objectives. All interviews were conducted in English. In addition, a desk review of the existing literature about Ghana's national health policies and systems, governance, and national COVID-19 preparedness and response plan was conducted to triangulate interview data and understand the context to conceptualize key themes from collected data (Table 1).

Table 1

Reviewed documents and data analyzed
Documents selected	Data analyzed
Policy responses to fight COVID-19; the case of Ghana [4]	Ghana’s national health policies and systems, governance
Ghana’s COVID-19 response: the Black Star can do even better [5]	Health systems and governance for COVID-19 response
Containing the impact of COVID-19: Review of Ghana's response approach [6]	National COVID-19 preparedness and response plan and Ghana’s health systems
How well is Ghana with one of the best testing capacities in Africa-responding to COVID-19? [8]	National COVID-19 preparedness and response plan and testing capacities
‘Test and trace' has worked for us, Ghana's President says [10]	Importance of 3Ts (test, tracing and treating) in Ghana
Saturation in qualitative research: exploring its conceptualization and operationalization [15]	Conceptualization of key themes from qualitatively collected data
How digital technology helped support Ghana's COVID response [17]	Health systems and surveillance using digital technology
Ghana receives critical COVID-19 medical supplies [19]	Health supplies and resource distribution

Data processing and analysis

Interviews were audio-recorded. To accurately capture the detail of full recorded data, SH and SY independently transcribed all the audio recordings verbatim. We combined both inductive and deductive approaches to coding. We employed the framework by following these steps: (a) familiarisation; (b) identifying initial codes; (c) indexing; (d) generating main, sub-themes and codes; and (e) defining and interpreting themes. In addition, we remained open to accommodate other themes. Coding was conducted manually, and a codebook was developed to identify and document all existing thematic categories. The selected core categorical themes were analyzed and compared with existing literature to ensure our findings' reliability, validity, and comprehensiveness [15].

Characteristics of the participants are shown in Table 2. The participants comprised policymakers, implementers, frontline workers, and community members. Most participants were implementers (75%) working in COVID-19 testing facilities and medical research institutions.

Table 2

Characteristics of participants
Key Participants	Characteristic	Total
Policymakers	Senior officials at Policy, Planning, Monitoring and Evaluation unit at the Ministry of Health (2)	2
Implementers	Laboratory managers from medical research institutions (6)	15
	Laboratory scientists from COVID-19 testing centers (4)
	Researchers from medical research institutions and Universities (5)
Frontline workers	Nurses from hospitals (2)	2
Community members	Community leader in Greater Accra (1)	1
Total		20

A total of 6 themes related to facilitators and barriers to scaling up COVID-19 testing, 12 sub-themes and 26 codes were derived from the analysis and coding process (Table 3). The results of the study are structured and presented in sections according to the main thematic areas and supported with quotes.

Table 3

Main, sub-themes and codes derived from the coding process
	Themes	Sub-themes	Codes
Facilitators	Health Governance and leadership for navigating COVID-19	Political leadership	• High political commitment to increase testing • High involvement of the President of Ghana to tackle the pandemic by increasing testing • High governmental effort for understanding the implementation of health regulations
		Community leadership	• Community leaders and organizations' commitments to enhancing adherence to COVID-19 protocols and testing • Religious leader's high commitments in educating community members to adhere to health regulations and get tested
		Multisectoral partnerships and collaboration	• High involvement of diverse entities from different sectors for financial support and distributions of health supplies
	Resource management	Human resources	• Training programs to strengthen health workers' capacity and ensure an adequate number of health workers • Availability of incentive packages for health workers • Positive attitude and behaviors of health workers towards work
	Resource management	Financial and material resources	• High financial commitments on the part of the government to ensure adequate financial and material resources • Availability of testing centers
	Information System	Surveillance systems	• Existence and use of a centralized data reporting system • Well-managed procurement and surveillance system
	Information System	Health communications	• Successful advocacy campaigns to ensure adherence to health protocols • Provision of regular updates on COVID-19 by the governmental authorities and health institutions
Barriers	Resources	Inadequate human resources to respond to growing needs	• Inadequate human resources in COVID-19 testing centers leading to heavy workload and its related consequences such as anxiety
	Resources	Financial and Material resources barrier to testing	• Low internet connection to manage data • Poor transportation infrastructure to deliver test samples • High price of COVID-19 testing • High dependency on reagents and consumables from other countries • Occasional shortage of reagents and testing kits
	COVID-19 infodemic	Socio-cultural perspectives and practices	• Strong reliance on negative experiences of people about COVID-19 testing to refuse testing
		Misconceptions about COVID-19 and testing	• Misinformation about COVID-19 • Low level of knowledge about COVID-19 leading to misconceptions, especially among rural residents and women
		Fear of stigmatization for testing positive	• Fear, anxiety and isolation associated with testing positive in the community
	Service Delivery		• Lack of opportunities for all community members to have equal and easy access to testing services

1. Facilitators of COVID-19 testing

1.1 Health governance and leadership for navigating COVID-19

1.1.1 Political leadership

The study revealed how effective leadership from the Government of Ghana positively influenced efforts to foster COVID-19 response strategy. Many participants confirmed the important role of political leadership in enhancing the general understanding of the Ghanaian population about the COVID-19 pandemic and response mechanisms, such as adhering to health regulations and getting tested. They reported that the President's guidance strongly influenced a sense of collective responsibility and encouraged people to adhere to response strategies, particularly on being tested against the virus. More importantly, participants emphasized that leadership and coordination between the government and the local authorities fostered a sense of collective responsibility and timely responses to the threats posed by the pandemic.

"It was very impressive the lots of hope received from the government and the President. Our President was really keen on tackling the pandemic, and with a lot of support from other governmental entities such as the Ghana Health Service and the National Commission for Civic Education (NCCE), we could respond to the COVID-19 pandemic timely. We were highly encouraged to get tested by the President, and his leadership uplifted the motivation of getting tested. "- Researcher from medical research institute 1

1.1.2 Community leadership

The majority of participants agreed that strong community leadership played an important role in distributing PPE, sensitization on the health protocols, and encouraging vulnerable groups to actively engage in the community to fight against COVID-19. According to our findings, community leaders and members played a critical role by successfully managing the pandemic through close collaboration with the Ghana government, health institutions, non-governmental organizations (NGOs), and other faith-based organizations. Further, community leaders, including religious leaders, helped provide public health education to members of their community using their local languages. This enabled community members, especially the illiterate, to understand the COVID-19 burden and the consequences of not adhering to health protocols.

"Many religious leaders from the churches are currently educating people to follow all COVID-19 protocols, such as wearing masks, washing hands, and being tested on the virus. We are doing our best to educate our members to follow the protocols and get tested timely. We also help them to disseminate identified information related to availing testing"- Community leader 1

1.1.3. Multisectoral partnerships and collaboration

Our findings revealed a high level of multisectoral partnership and engagements of diverse sectors such as intergovernmental organizations, religious institutions, civil society and the private sectors. Study participants recounted how engagement with the private sectors for financial and material support enhanced COVID-19 testing capabilities, including setting up major testing centres across the country and ensuring testing kits and supplies. For example, private centres like Nyaho Medical Centre and Frontiers Health Care Services are major testing centres of the country. The development partners also assisted with the provision of laboratory equipment and the logistics for testing.

"…… we have been supported by various private companies, NGOs and ministries. The private companies and some NGOs helped some vulnerable groups with health supplies and funds for COVID-19 testing. My institution was also given some financial and material support from them such as reagents for a test." – Laboratory manager 1

1.2. Resource management

1.2.1. Human resources

Study participants indicated that there are sufficient health professionals and training programs and platforms that sort to enhance the capacity of health workforce to fully meet up to task. Also, interviews highlighted that there were several incentive packages for health workers, including insurance packages and tax relief [16]. According to the opinions of some participants, this enabled them to exhibit a positive attitude at work. Also, the training improved the confidence level and interpersonal relationships between the health professionals and their clients.

"We have been provided extensive training and go through a series of training for three weeks or one month. We learn everything from whole processes of sample collecting to how to make patients calm down to make sure that they are comfortable when taking a nasal pharyngeal swab." - Laboratory scientist 1

1.2.2. Financial and material resources

Provision of financial resources is key in ensuring adequate health supplies to foster timely response to the COVID-19. Participants mentioned the commitments of the Ministry of Health (MoH) in ensuring adequate financial and material resources in upscaling testing. They further emphasized that support from individual donors, international organizations, and NGOs enabled the government to achieve this goal.

"We did not have enough testing centers and PPE at the beginning of the pandemic. But now have many facilities for COVID-19 testing, adequate PPE and other consumables supported by the Ghana government, international organizations and other donors. For example, Ghana airport testing center was recently established and offers COVID testing at the Kotoka International Airport." – Laboratory manager 2

Further, most participants emphasized that the availability of more testing centers, infectious disease centers, sustainable funding initiatives such as the establishment of the COVID-19 National Trust Fund (CNTF), and funding programs for enterprises all contributed to successful COVID-19 responses in Ghana, including testing. A senior official at MoH mentioned that "We established COVID-19 Alleviation and Revitalization of Enterprises Support (CARES) programme to mitigate the impact of the pandemic on the livelihoods of Ghanaians and support businesses and workers, and introduced Coronavirus Alleviation Programme (CAP) to formulate and implement the COVID-19 preparedness and response plan, tracing, testing, and treatment."

1.3. Information system

1.3.1. Surveillance systems

Participants revealed the establishment of a central procurement system and a surveillance system was vital in COVID-19 preparedness and response and provision of essential services. A senior officer at MoH said, "We have a good surveillance system to rapidly detect, test and manage cases to monitor the virus, and Ghana Health Service can see all available data at one glance using it. We also have a good, systemized procurement system through procurement agencies."

Further, real-time surveillance of reported COVID-19 infections has been key to the global pandemic response. Many tools, devices and apps have supported surveillance in Ghana [17]. Participants emphasized the role of the centralized data reporting system in Ghana called Surveillance Outbreak and Response Management and Analysis System (SORMAS). According to interviewees, the system enabled health professionals to identify defaulters and get them tested. They also pointed out that it helped monitor stock to avoid shortages of materials for testing, such as test kits and PPE.

"The Ghana Health Service traces all positive cases based on collected data. It helped connect all labs across districts to access to it, also, helped detect, investigate and control the virus in the long run." – Laboratory manager 3

1.3.2 Health communications

Public health communication plays an important role in protecting public health during pandemics. According to the interviews, the Government of Ghana effectively provided information through various public media to the people, particularly by educating them on measures that need to be undertaken to contain the spread of the virus. Participants asserted that mass media campaigns on adherence to health protocols and regular updates on COVID-19 by the President and health authorities positively influenced community members to adhere to health directives. A researcher from the University pointed out, "There are several TV and radio advertisements, and they compelled to educate people. The advertisements ensured that concepts and materials on COVID-19 testing are seen as culturally relevant and well understood by people."

2. Barriers to COVID-19 testing

2.1. Resources

2.1.1. Inadequacy of human resources (testers) to respond to growing needs

Interestingly, 55% of participants agreed that the government's effective interventions in the health sector helped bridge the gap between demand and supply of human resources, while the same proportion of participants (55%) complained that despite the government's effort, there is still an issue of limited human resources, especially in COVID-19 testing centers. A laboratory manager recounted, "We have only one person at the lab who runs the test. Despite our support, he ran samples until late. I also feel too exhausted and tired when testing many people. The human personnel are fewer. One of the reasons is that some people may think it is too dangerous, and maybe they can use the same expertise to bring more changes in the science field, Ghana."

Some health professionals also revealed that they experience high stress and burnout due to heavy workload during the prolonged pandemic. A nurse said, "I think we have been demotivated for the past years. We are risking our lives during the pandemic, and sometimes it makes us miserable and stressful despite our passion for patients."

2.1.2. Financial and material resources barrier to testing

According to findings of the study, poor infrastructures such as low internet connectivity and an inadequate transportation system posed a challenge to effective delivery of collected blood samples, thereby delaying test results and data loss. Again, there was difficulty in transporting tools and equipment due to the poor roads.

"The main issue is logistics and transport to deliver blood samples to national labs in Accra (the capital city and where testing labs are located). When we were supposed to leave to take samples outside from the community, the car wasn't ready. This was the challenge during the collection of samples and taking samples to Accra." – Laboratory manager 4

The Ghana government received COVID-19 medical supplies from international organizations to be given to hospitals and clinics to scale up the COVID-19 response effort in 2021 [18–19]. However, the majority of participants asserted that the cost of being tested was high for the majority of people, thereby deterring people from being tested. A laboratory scientist mentioned, "The government should do something about Covid-19 tests by reducing the price or making it free for the ordinary people because most people who do not have a prescribe from doctors are reluctant to pay expensive testing fees and get tested."

Also, participants indicated that the high dependency on imported reagents and consumables from other countries poses a challenge to an effective response to the growing threats, especially whenever such products become scarce in the donors' countries. According to participants, this contributed to the occasional shortages of material resources such as reagents and testing kits. A researcher at the medical research institute reported, "There is currently a shortage of health supplies for testing. This occasionally happens when more people want to get tested and know their status. So, this is very important."

2.2. COVID-19 infodemic

2.2.1. Socio-cultural perspectives and practices

This study revealed a salient aspect of how socio-cultural perspective of members of the Ghanaian community influenced testing and general response to COVID-19. Participants expressed a dilemma as to how people are impacted by Ghanaian culture positively and negatively. Participants mentioned some positive cultural impacts on COVID-19, such as practice of hand hygiene [20]. On the other hand, study participants mentioned other negative socio-cultural influences on people's behavior and beliefs towards adherence to COVID-19 protocols, for example, a high dependency on neighbor's negative personal experiences about COVID-19 testing rather than from the health experts. Thus, people would like to be tested based on shared experiences of their close friends and relatives. A laboratory scientist mentioned, "Ghanaians are particular about maintaining relationships with family and friends. So, when the pandemic occurred, people shared their uncomfortable experience with nasal swabs for testing, and some of them have a fear of getting tested."

2.2.2. Misconceptions about COVID-19 and testing

Almost all the participants pointed out some misconceptions about COVID-19. They emphasized that some people hesitate to get tested because they consider COVID-19 as just common flu. Further, some people believe in rumours that coronavirus does not exist. According to our findings, these factors influenced the decision of community members to be tested for COVID-19.

"Some people believe in fake news and misinformation that the virus is not real, so vaccination and testing is unnecessary. Also, they think COVID-19 is just like flu, and big countries are using it for political purposes " – A community leader 1

"I have a patient who has a misconception that the virus does not exist. So, I think educating them to adhere to health protocols using TV and radio is important." – A nurse 1

Further, participants narrated that community members do not have the same level of knowledge or information about the virus and how to adhere to health protocols. A senior officer at MoH cited, for example, that the level of educated men is higher compared to women, "Education will actually make a lot of difference in the heart of people concerning the COVID-19 and its right information. However, at the same time, I feel that illiteracy among women can be a barrier, especially in rural areas. Unfortunately, they (women) have fewer opportunities to be educated than men."

2.2.3. Fear of stigmatization for testing positive

Some participants also shared their experiences with patients and community members. According to them, most people were afraid of being isolated and stigmatized by their members of the public, including their workplaces and community. Respondents highlighted the feeling of guilt and shame for people testing positive, which deters others to come for testing.

"If you are diagnosed as COVID-19 positive, people will not even allow you to go to this particular neighborhood; for example, as a COVID-19 worker, people think that I will also be infected by the virus one day. So they try not to be close to me." - Laboratory scientist 2

2.3. Service delivery

Ghana's health care structure is regarded as well-developed compared to other countries in sub-Saharan Africa [4]. There are five levels of providers and include health posts, health centers and clinics, district hospitals, regional hospitals and tertiary hospitals. The aim of this decentralization process is to improve accountability to local population, efficiency in service provision, equity in access and resource distribution, or to increase resource mobilization [21]. However, this decentralized system and its functions have not been as effective as they could have been in the outskirts of Accra. A nurse working at a remote hospital from the Greater Accra said, "Like mining town, everybody says they do not have equal opportunities to access good healthcare services compared to the capital city, Accra. Full attention and support for the people in rural areas is really needed."

This study is part of a two-country study that sought to identify factors influencing COVID-19 testing in Bhutan and Ghana. For findings on Bhutan’s case study [11], this current study illuminates the facilitators and barriers to COVID-19 testing in Ghana. In that paper, six enablers and five barriers were identified. Major enablers were: political leadership, community participation, multisectoral collaboration, improved financial support and better human resource management, improved surveillance system and health communication, while key barriers were inadequate frontline workers, poor infrastructure, socio-cultural perspectives and practices, misconception about COVID-19 and fear of stigmatization for testing positive. An in-depth comparative analysis of both studies is forthcoming.

Effective health governance and leadership is crucial during pandemic preparedness and response. According to the evidence collected from this study, a combination of leadership from the community levels to the high political level and multisectoral partnerships across institutions contributed enormously enhanced good health governance for timely response to the COVID-19 pandemic in Ghana. This also contributed to efficient management of resources, including ensuring availability of human and material resources such as a well-established surveillance system for effective mass COVID-19 testing. Study finding supports studies showing that collective efforts from multisector to build a mass testing capacity by increasing the availability of health workers, establishing more testing centers, and reporting consistent data has a positive impact on encouraging more people to get tested and steer its scale-up strategies [22–24]. The findings also highlight why and how these factors influence people's behaviors to get tested and public and private actions to cut the COVID-19 transmission.

Many barriers to testing identified in this study are exacerbated by the inadequacy of resources and their management. One salient finding from the study is that while human resources were not inadequate, there existed the challenge of uneven distribution of health workforce, especially frontline workers responsible for testing. Participants reported the inadequacy of frontline workers in rural areas compared to urban settings. The situation is not different with availability of other material and financial supports across diverse settings. The finding has profound implications for the need for collective political commitments to ensure efficient and effective allocation of equally distributed resources in both rural and urban. Other studies have also highlighted how adequate preparation and response to outbreaks necessitate resources for expansion of COVID-19 testing capacity. Besides, scarce resources pose a challenge to ensuring adequate access to testing, especially for vulnerable populations [24], including the poor, who cannot afford to pay to be tested.

Health care information and communication strategies are also crucial for effective response to diseases outbreaks. As a result, many countries institute a myriad of strategies to improve information systems. Lack of proper communication and information may lead to several unplanned consequences, a misconception that may intend to influence response strategies during a pandemic outbreak [25, 27]. Misconceptions about COVID-19 are considered one of the key challenges faced by many countries [26]. This is mainly fascinated by fake information consumed by community members. For example, fake information about COVID-19 has misled people into low adherence to health protocols [25–27]. Based on the findings of this recent study, community members desisted from being tested due to misconceptions about the virus. The fear of being stigmatized even heightens this challenge. Notwithstanding that, misconceptions about the COVID-19 disease are significantly prevalent among rural residents [27]. The findings renew the need to enhance public health education and community sensitization on major infectious diseases risks [26–27], through active community engagement targeting the vulnerable groups.

Implications for policy and practice

Based on the findings of the study, we anticipate the following recommendations could help stimulate strategies for scaling up COVID-19 testing:

Strong political commitment is required to ensure adequacy and even distribution of resources to strengthen testing capacity at all levels of health care delivery, especially among vulnerable groups and settings.
Provision of accurate and up-to-date information about COVID-19 disease could address the problem of misconception and stigmatization, which causes community members not to adhere to pandemic preventive measures. But more can be achieved when community members are fully empowered to develop and implement community-led pandemic preparedness and management of infodemic to help reduce its impact on negative health behaviours during health emergencies.
Again, while an improved surveillance system could foster provision of valid and timely information to guide public health actions, efforts should be geared towards improving how information is communicated to community members. Therefore, stakeholders, including politicians, community leaders and advocates, and health professionals, should be provided with the needed training to enhance their communication skills. This we envision could help minimize the several misconceptions and stigmatization around COVID-19 response, which influences one’s decision to test the virus.

Strengths and limitations of the study

This study has strengths and limitations. To the best of available literature, COVID-19 testing strategies have not been thoroughly studied yet. This is the first study of its kind to explore facilitators and barriers of COVID-19 testing in Ghana. We were able to explore information from different stakeholders with diverse backgrounds and experiences, thereby enhancing the comprehensiveness and rigor of our findings, relevant for decision making.

Regarding the limitation, interviews were conducted virtually. This limited us from performing field observation and Focus Group Discussions (FGDs), which we believe could have enhanced study rigor. Nevertheless, this does not limit the credibility of our findings as data were compared with existing literature to enhance data triangulation. Besides, we stopped data collection when saturation had been reached. Moreover, this study included participants based in Greater Accra and peripheral of Accra. We, therefore, encourage further studies to be conducted beyond the boundaries of Accra.

Testing for COVID-19 remains a vital strategy to contain spread of the infection. It can help health workers to easily trace, isolate and treat positive clients and monitor the dynamics of the pandemic. But testing barriers can be significant impediments to COVID-19 response. This study documents enablers and barriers to COVID-19 testing in Ghana. Better health governance and political leadership, community participation, multisectoral collaboration, good management of resources, improved information/surveillance system and health communication were key enablers of COVID-19 testing. Findings also revealed a strong political willingness to committing financial resources to enhance testing capabilities. The primary barriers to testing were mainly COVID-19 infodemic, inadequacy of material resources, and long waiting time to receive results after testing. Further, although human resources were not inadequate, they were unevenly distributed across settings.

To be prepared to scale up testing and to effectively respond to future outbreaks, the following are recommended: there should be improved political commitments to ensure even distribution of human and material resources across both rural and urban settings; financial supports should provide to the poor to protecting them from the financial consequences of paying for testing services; improving community participation to address socio-cultural barriers to testing hesitancy. But multilateral cooperation with diverse stakeholders beyond the scope of health will be crucial in facilitating pandemic response like scaling up testing strategies.

WHO

World Health Organization

PHC

Primary Health Care

NHIS

National Health Insurance Scheme

UHC

Universal Health Coverage

SDGs

Sustainable Development Goals

CHPS

Community-Based Health Planning and Services

PPE

Personal Protective Equipment

EPHF

Essential Public Health Functions

CNTF

COVID-19 National Trust Fund

NCCE

National Commission for Civic Education

CARES

COVID-19 Alleviation and Revitalization of Enterprises Support

SORMAS

Surveillance Outbreak and Response Management and Analysis System

FDGs

Focus Group Discussions

Acknowledgements

The authors are grateful to the study participants. We gratefully acknowledge Dr Aku Kwamie for her technical contribution and members of the Alliance for Health Policy and Systems Research for their support.

Data availability statement

The dataset can be made available upon reasonable request from the corresponding author.

Ethics declarations

This study was approved by the Ghana Health Service Ethics Review Committee (No: GHC-ERC 05/07/2021). Informed written consents were obtained from all study participants before the interviews. All participants were assured of their privacy, confidentiality and anonymity of data provided. Participation was voluntary, and participants were given the right to withdraw from the study at any given point.

Funding

Not applicable

Author's Contributions

SH, SY, and AA, conceived the study, performed data collection and analysis and developed the manuscript. The final manuscript was approved by all authors.

Competing interests

None declared

Consent for publication

Not applicable

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COVID-19 testing: A qualitative study exploring enablers and barriers in the Greater Accra Region, Ghana

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Version 1

Abstract

Introduction

Methods

Study design, sampling and data collection

Data processing and analysis

Results

1. Facilitators of COVID-19 testing

1.1 Health governance and leadership for navigating COVID-19

1.1.1 Political leadership

1.1.2 Community leadership

1.1.3. Multisectoral partnerships and collaboration

1.2. Resource management

1.2.1. Human resources

1.2.2. Financial and material resources

1.3. Information system

1.3.1. Surveillance systems

1.3.2 Health communications

2. Barriers to COVID-19 testing

2.1. Resources

2.1.1. Inadequacy of human resources (testers) to respond to growing needs

2.1.2. Financial and material resources barrier to testing

2.2. COVID-19 infodemic

2.2.1. Socio-cultural perspectives and practices

2.2.2. Misconceptions about COVID-19 and testing

2.2.3. Fear of stigmatization for testing positive

2.3. Service delivery

Discussion

Implications for policy and practice

Strengths and limitations of the study

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

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