Our sample included 21 CHOs and 10 SDLs, for a total of 31 participants across 23 CHPS sub-districts. Respondents discussed barriers to CVD care – and solutions to these challenges – across three themes: community demand for CVD care; community access to CVD care; and provider capacitity to render CVD care. A coding tree, which can be found in the appendices, depicts these three themes as well as ten sub-themes – each directly informed by our (fifteen) main codes and their sub-codes. Themes and sub-themes were grounded in the content of the IDIs via those codes, developed in turn by the constant comparative analysis of data detailed above. All analysts found that the sample achieved a high degree of thematic saturation.
I. Community Member (Demand-Side) Engagement Barriers to CVD Care
This theme refers to challenges NPHWs face with rendering CVD care. These challenges include high risk factor burdens, poor health literacy, and other community member factors.
Many participants believe that the communities that they serve experience a high burden of CVD risk factors. These risk factors include stress, alcohol and tobacco use, diet, and sedentary lifestyle.
Most SDLs say that stress, particularly family-related stress, is a leading cause of CVD in their communities. Participants pointed to several common stressors, such as family problems, work, overthinking, and emotional triggers. Common family problems included being “abandoned” when one’s children move to cities, being childless and unable to support oneself, having children who are “useless,” bad marriages where one is commonly insulted, and not being able to afford school tuition for children. Respondents spoke often about stress due to the migration of youth to nearby cities and towns. This has created an unprecedented problem in rural Ghana as traditional support for the elderly has declined. These social dynamics are described by an SDL:
“Some people have got a lot of problems.… Like you have delivered your children, all of them have run away and left you alone. You are old, and you are still doing everything for yourself. You see, that is a problem that can give you heart disease. And at times, some people don’t even have children. If you don’t have a child, how do, you see, you are old, and you needed somebody to support you, there is nobody to support you. So that, all that will lead to heart disease.” (SDL)
Participants were also worried about the degree of alcohol consumption that they see in their communities, and its implications for CVD and community health more generally. As one SDL describes,
“To me, the biggest one is the alcoholism…. Anywhere you move you see that everyone is just drunk, drunk, drunk.” (SDL)
This concern was compounded by the belief that patients are not forthcoming in speaking about their alcohol use with CHOs. Some CHOs have attempted to intervene on patients who use alcohol excessively, either by creating a therapeutic alliance with them or by involving their families, with varying levels of success.
Respondents reported that many community members smoke tobacco, and that this behavior is particularly common among men and youths:
“This is a tobacco farming community, and we all know that smoking is a very high-risk factor. And almost all the youth in this community smoke excessively, so actually it’s a problem here. The smoking. Almost all the youth, even teenagers, smoke here.” (CHO)
Several CHOs say that they are encouraged by their SDLs to counsel patients regarding the risks associated with smoking and the benefits of smoking cessation. Some CHOs found, however, that patients often try to conceal their smoking status from NPHWs.
Finally, numerous participants feel that community members’ diets and sedentary lifestyles put them at high risk for CVD. The diets described were heavy in salt, fat, meat, and soda, and deficient in vegetables. Some respondents say that they often counsel patients on the benefits of diet and exercise. One SDL describes that these conversations can be difficult, however, due to conflicting cultural attitudes regarding diet, exercise, and weight:
“We don’t see the need to exercise. We don’t see the need to diet. You feel that growing big is something that is good in our society, that’s what they think. When you are big, it’s a sign of good living.” (SDL)
In addition to having many CVD risk factors, a preponderance of participants feel that community members lack a basic understanding of the symptoms and health consequences of CVD. As a result, individuals who develop CVD symptoms sometimes eschew care and as several respondents describe, instead attribute these symptoms to other diseases, such as malaria, or to divine judgment. Many note that due to a combination of these factors, individuals who are afflicted with CVD are often unaware of their illness.
Medical screening of asymptomatic individuals for NCDs is exceedingly rare in Ghana [59], which likely contributes to this low level of health literacy. In fact, many community members are unfamiliar with the concept of preventative screenings and asymptomatic treatment. This lack of familiarity was described by numerous respondents:
“It’s lack of knowledge…. If you do not visit them, they don’t know what check-ups are…. So, they sit at home and then develop the pressure without managing it.” (CHO)
“Some of them, when it is better, they don’t take the medication. That is one problem we can face. They don’t take the medication because they think they are fine.” (CHO)
Several respondents note that once diagnosed with CVD, community members do not feel comfortable discussing their health problems, representing a barrier to care. Participants mentioned patients who do not inform friends and family of their CVD because they do not want to burden them with the costs of their treatment. Others do not want to discuss their CVD because they do not understand the serious implications of their illness. Some CHOs also mentioned stigma surrounding CVD:
“They think when they share it out and you also tell others. Maybe this house gets to know that that house has someone suffering from this condition it means they will lose respect or something like that, so they will not even like others to know.” (CHO)
Once connected to care, some patients demonstrate poor adherence to CVD treatment. CHOs routinely survey medication adherence both at CHPS compounds and on home visits. They say that community members often become ill because they discontinue their medications when they are feeling better. However, the reasons for community members’ poor adherence are likely multifactorial, including fear of potential side effects, cost, misunderstanding, polypharmacy, and lack of symptoms [60].
II. Poor Access to CVD Care at CHPS
This theme refers to community members’ difficulty obtaining care for CVD. Respondents described difficulty due to cost, distance, and other barriers to reaching a CHPS site, independent of the logistics of CHPS itself.
CHPS workers say that they most often encounter heart disease patients on home visits, because these patients generally do not come to CHPS to receive care. As described by a CHO:
“[T]hey don’t come into the facility with that condition. Unless when we do home visiting and we identify them. (CHO)
Several participants said that patients with heart disease used to come to CHPS compounds more often. However, they do not anymore, because CHPS compounds no longer carry CVD medications.
“Some of the treatments for the other diseases, we don’t have them here. So, somebody will say ‘Why do I waste my time to come to this clinic, come and expose myself to them, after all they are not going to give me any treatment.’.... So, it’s better that I go to Navrongo than come to this facility.” (CHO)
At present, CVD care is largely provided at referral centers. However, patients experience barriers to receiving care at these centers. Referral centers are often far away from the communities in which patients live; even when geographically close, many patients lack the means of transport to get there. Some patients, particularly the elderly, require help getting to referral centers, but do not have anyone to accompany them.
“Especially, the elderly one. Those who don’t also have someone to support them…. So, if the person cannot walk to Navrongo, there is no money to transport to Navrongo, so the patient will not go.” (CHO)
Cost is a large barrier to receiving care at referral centers. Many patients will pay others for the fuel or vehicle needed for transport. But as referral centers often draw from low resource areas, this cost can be too great for some, as outlined by numerous participants:
“Sirigu is nearer, but before the person even gets there, maybe that person will need a motor rider, that person will need fuel, and that person has no money. And to talk of Navrongo, when you mention Navrongo, they even get frightened. So actually, it’s very difficult for them.” (SDL)
“You know when she came, and I mentioned referral, the mother went back to the house…. I’m sure they have to go to the market to look for the money, but when they get there, by all means, they will not buy medicines, they will have to eat and other things. So, the poverty level here is very high so when you are referring.” (SDL)
“You see, this village like this is a deprived village. They don’t have money. So, some of them, it is really a problem to them.” (CHO)
Respondents describe significant barriers to accessing CVD care, namely CHPS-related limitations, lack of transportation, distance to referral centers, and high costs. As a result of these barriers, many patients with CVD or CVD risk factors such as hypertension are not able to successfully access care.
III. Community Health Center (Supply-Side) Barriers to CVD Care
This theme referred to challenges that CHOs and the CHPS program face with rendering CVD care. We found that these challenges include gaps in training, logistics, and other structural factors.
While respondents highlighted strengths with regards to the CHOs’ training, most participants, particularly SDLs, expressed that CHOs lack important knowledge about CVD. CHOs were confident in their knowledge of topics such as CVD risk factors and detection. However, in a quiz administered at 21 CHCs, CHOs showed gaps in knowledge about CVD risk factors and causes, as well as about the diagnosis and treatment of CVD.
Due to CHPS’ origins as an organization primarily focused on improving maternal and child health, CVD has not historically been at the core of CHO training. During their schooling, CHOs receive training about CVD that focuses primarily on prevention and diagnosis. However, many SDLs felt that this training is insufficient. Further, many CHOs expressed that they had not learned enough about CVD during their training. This sentiment was expressed by an SDL:
“[CHO knowledge of heart disease symptoms is] not adequate per my own assessment. Because some of them, they can’t even tell you the treatment you give to maybe a patient with high blood pressure, diabetic, stroke.” (SDL).
Contributing to these knowledge gaps is lack of exposure. Participants felt that knowledge gained during training is lost over time because CHOs do not often see CVD patients at CHPS facilities.
“After school scarcely will you open the book again…. But with the refresher training, it reminds you of the things you have forgotten, then you are refreshed to do the work better.” (CHO)
As such, almost every CHO said that more in-service trainings would help them better understand and care for CVD. Participants felt that trainings should focus on CVD prevention, symptoms, management, and treatment.
In addition to enhanced training, participants expressed that they also require materials including medications, blood pressure monitors, motorbikes, and fuel in order to provide adequate care for CVD and its risk factors at CHPS compounds. Presently, most CHPS compounds do not carry essential medications for CVD risk factors such hypertension, hyperlipidemia, and diabetes. This is because the National Health Insurance Scheme (NHIS) does not reimburse CHPS compounds for disbursing medications such as antihypertensives, statins, and antihyperglycemics. As a result, patients are forced to travel to larger regional health centers for treatment. As outlined previously, because these facilities are farther away and transportation to them is poor, patients often choose not to go, and instead live with untreated CVD or CVD risk factors. For these reasons, participants feel that NHIS’ decision to not reimburse CHPS for these medications is making their communities sicker.
While CHOs may not dispense medications, they are currently able to screen for, diagnose, monitor, and manage straightforward cases of CVD, as well as to refer to regional health centers. Some participants felt that this level of care was not adequate to help patients with conditions such as hypertension. Others say that they turn CVD patients away because they know that they are unable to treat them. At times, patients do not understand the limitations placed on CHPS compounds, and this can be discouraging for CHOs. As one CHO states,
“They ask you questions like, ‘Now you come and stand and talk like this. How come when I tell you people, well I’m having BP, my drugs, you tell me I should go to hospital? Then what are you people doing?’ You see that? So sometimes those things discourage us. We feel bad. We just wish that we could be able to do it.” (CHO)
Most CHOs want to be able to treat CVD pharmacologically at CHPS compounds. Many participants felt that with more training, CHOs would be capable of treating straightforward CVD cases with medications. They feel that this effort would be beneficial to patients by making these medications more accessible.
“They can treat by sometimes giving some of the health centers, the smaller clinics, the opportunity to also treat…. Because some of us, we don’t have access to treatments. We only monitor, refer. And here, like this one, you tell them to go to Navrongo, it’s like you cursed them or something. They don’t want to go.” (CHO)
Many CHOs want a return to the “old system” in which NHIS reimbursed CHPS compounds for CVD medications. They feel that this would reduce the burden on low-income patients and increase medication adherence.
“Most of the hypertensive cases who are put on drugs as they grow older, some today is on the drug, tomorrow the person is not. When asked why, they go ‘Oh, I don’t have money to buy.’ But if GHS is able to come out with drugs, that will cover health insurance, people will get with it.” (CHO)
In addition to medications, most participants claimed that their facilities lack equipment and materials necessary for managing CVD. Notably, they held that more blood pressure apparatuses are needed for adequate care. Several CHOs reported one apparatus was available at their facility; some CHPS compounds had none. Their absence prevents routine blood pressure surveillance during outreach and home visits, necessitating referral of patients to hospitals or CHCs for routine blood pressure readings. Non-adherence with such referrals thus impedes the provision of even the most basic of CVD interventions, as described by a SDL:
“Even to go around with the common BP apparatus, they don’t have. For the facility, we have one and it breaks down very often. So, they don’t have. They only refer per symptoms…. It’s the BP apparatus that you use to measure, and if it’s broken down, you can’t tell whether the person’s BP has risen, whether it’s gone down.” (SDL)
Participants also lack the motorbikes and fuel required to go on home visits and to take patients to the hospital. Some say that due to NHIS underfunding, they currently use their personal motorbikes and fuel to transport patients, because many patients cannot afford their own transport:
“We go into the communities such cases, we interact with people, attend to old, the aged and all those things. Now we don’t have motor bikes, we don’t have fuel…. These are some of the things hampering the work. If those things are improved, it will go a long way to help.” (CHO)