ABSTRACT
Background: Rigorous evaluations of health system interventions to strengthen hypertension and cardiovascular disease (CVD) care remain scarce in sub-Saharan Africa. This study aims to evaluate the reach, effectiveness, adoption / acceptability, implementation fidelity, cost, and sustainability of the Ghana Heart Initiative (GHI), a multicomponent supply-side intervention to improve cardiovascular health in Ghana. Methods: This study adopts a mixed- and multi-methods design comparing the effects of the GHI in 42 intervention health facilities (i.e. primary, secondary and tertiary) in the Greater Accra Region versus 56 control health facilities in the Central and Western Regions. The evaluation design is guided by the RE-AIM framework underpinned by the WHO health systems building blocks framework, integrated by the Institute of Medicine's six dimensions of health care quality: safe, effective, patient-centered, timely, effi cient, equitable. The assessment tools include: (i) a health facility survey, (ii) a healthcare provider survey assessing the knowledge, attitudes, and practices on hypertension and CVD management, (iii) a patient exit survey, (iv) an outpatient and in-patient medical record review and (v) qualitative interviews with patients and various health system stakeholders to understand the barriers and facilitators around the implementation of the GHI. In addition to primary data collection, the study also relies on secondary routine health system data, i.e., the District Health Information Management System to conduct an interrupted time series analysis using monthly counts for relevant hypertension and CVD specific indicators as outcomes. The primary outcome measures are performance of health service delivery indicators, input, process and outcome of care indicators (including screening of hypertension, newly diagnosed hypertension, prescription of guideline directed medical therapy, and satisfaction with service received and acceptability) between the intervention and control facilities. Lastly, an economic evaluation and budget impact analysis is planned to inform the nationwide scale-up of the GHI. Discussion: This study will generate policy-relevant data on the reach, effectiveness, implementation fidelity, adoption / acceptability, and sustainability of the GHI, and provide insights on the costs and budget-impacts to inform nation-wide scale-up to expand the GHI to other regions across Ghana and offer lessons to other low- and middle-income countries settings as well. RIDIE Registration Number: RIDIE-STUDY-ID-6375e5614fd49 (https://ridie.3ieimpact.org/index.php).
ABSTRACT
BACKGROUND: A previous multi-site study involving lower- and middle-income countries demonstrated that asthma in older adults is associated with long-term exposure to particulate matter, male gender and smoking. However, variations may occur within individual countries, which are relevant to inform health promoting policies as populations live longer. The present study estimates asthma prevalence and examines the sociodemographic characteristics and environmental determinants associated with asthma in older adults in Ghana. METHODS: This study utilised data from the nationally representative World Health Organization Study on global AGEing and adult health (SAGE) Ghana Wave 2. A final sample of 4621 individuals residing in 3970 households was used in analytical modelling. Factors associated with asthma were investigated using single level and multilevel binary logistic regression models. RESULTS: Asthma was reported by 102 (2.2%) respondents. Factors associated with asthma in the univariate model were: those aged 60-69 (OR = 5.22, 95% CI: 1.24, 21.95) and 70 or more (OR = 5.56, 95% CI: 1.33, 23.26) years, Ga-Adangbe dialect group (OR = 1.65, 95% CI: 1.01, 2.71), no religion (OR = 3.59, 95% CI: 1.77, 7.28), having moderate (OR = 1.76, 95% CI: 1.13, 2.75) and bad/very bad (OR = 2.75, 95% CI: 1.58, 4.80) health state, and severe/extreme difficulty with self-care (OR = 3.49, 95% CI: 1.23, 9.88) and non-flush toilet facility (OR = 0.62, 95% CI: 0.39, 0.99). Factors independently associated with asthma in the adjusted models were: those aged 60-69 (OR = 4.49, 95% CI: 1.03, 19.55) years, father with primary education or less (OR = 0.40, 95% CI: 0.17, 0.94), no religion (OR = 2.52, 95% CI: 1.18, 5.41), and households with non-flush toilet facility (OR = 0.58, 95% CI: 0.35, 0.96). Significant residual household-level variation in asthma was observed. Over 40% of variance in asthma episodes could be attributable to residual household-level variations. CONCLUSION: Individual as well as household factors were seen to influence the prevalence of asthma in this national survey. Clinical management of these patients in health facilities should consider household factors in addition to individual level factors.
