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Table 4 Facilitators and barriers to implementation of a culturally adapted skills-based stroke education tool

From: Adapting a skills-based stroke prevention intervention for communities in Ghana: a qualitative study

 

Facilitators

Barriers

Implementation outcomes

 

Acceptability

Attitudes/burden/self-efficacy/intervention coherence

Attitudes

• Participation motivated by desire to care for self and children/grandchildrena

Burden

• Delivered as one-on-one discussion from provider, potentially with patient’s partner or caretakerc

• Community nurses already going out in communities to address people’s fears of the medical systeme

Self-efficacy

• Some hypertensive community members already seeking information/advice from multiple sourcesa,b

Intervention coherence

• Successful hypertension management modeled to patients through images and storiesb,c

• Show how people struggle with strokec

• Provide audio aids for patients to take home with theme

Attitudes

• Religious beliefs encourage “preemptive rejection”/denial of ill-healthc,f

• Spiritual etiology of ill health is normalized and requires spiritual interventiona,b,c,d,e,f

• Some fear hypertension diagnosis caused by BP screeninga

• Experienced or anticipated medication side effects for men (erectile dysfunction, low libido, “feeling uncomfortable”)a,c,d,e; for women, diabetes onseta

Burden

• Patients screened in the community expect to be treated on the spot, rather than receiving a referral to the hospitale

Self-efficacy

• Self-efficacy regarding taking local herbs/alternative medicines, not hypertensive medicationsa

Intervention coherence

• Locus of control—some nurses see the patient’s lack of discipline as reason for their inability to adhere to medication regimenb—this was not mentioned by patientsa

Adoption

Implementers

• Community and clinical nurses see themselves implementing, with trainingb,c,e

• Physicians do not perceive themselves as best implementersd,f

Appropriateness

To address hypertension

• Screening and education should be delivered together

 

For potential beneficiaries

• Use simple language and translate in different languagesc

• Utilize a cultural insider/community member to deliver health messaged

• Successful implementation is more likely if delivered by community opinion leaders,c,d particularly the churchc

• Culturally significant gender roles and expectations important for tailoring messaginga,b

 

For implementers

• Educators should warmly welcome patients at the beginning of the educational sessionc

• Physicians do not perceive they have time to educateb,c,d,f

• Community nurses have varying levels of training and ability to educate patientsd

• Community nurses have broken equipment to monitor BP in the communityb,e

For setting

• Places in which the intervention could be implemented: at home, in the clinic, at market, at clan meetings, at durbars, in schools, and at churchb,c,d,e,f

• Unregistered salesmen, who may even refer to themselves as “doctor,” going around in the community offering to check BP, then using the opportunity to sell drugs to individual who may or may not need itb,c

• The herbalist has time to educate, the clinician does notd

• Community health nurses need transportation to reach communities in needb

• Not enough BP machines in community settingb,e

• Nurses are already trying to screen and educate in the community, but lack educational materials (i.e., fliers, posters or visuals showing conditions due to hypertension), logistics and fundse

• Community distrust of the biomedical establishmentb,d

• Relative advantage of alternative health systems (herbalism, use of natural foods like pepper or ginger, traditional medicine, Chinese medicine, prayer camps), which promise total cure and easier dosage while biomedical approach requires continuous managementb,c,e,f

• Patients fear maltreatment in the medical systemb,c,e

• Patient inconveniences like long wait times, language barriersb

Cost

Opportunity cost

 

• Physicians do not perceive they have time to educate patientsb,d,f

Patient cost

 

• In spite of knowing their hypertension status, some people cannot seek treatment due to povertye,f

• Patients report cost of having to go monthly to renew prescriptiona

• Cost for medications not covered by NHISf

• Although medications are supported by NHIS, many people do not register due to sense of fatalismb or mistrust of the health systemc

Implementation cost

 

• Nurses lack funding for educational materials and maintaining BP screening equipmente

Feasibility

• Feasible to implement in clinical or community settingd

• Some presence of social support to manage hypertension among close family and friend networksa

• Community health workers have variable capacity for educating due to their trainingd

• Perceived lack of healthcare support by hypertensive individuals given poor provider-patient communicationa

• Lack of a seamless continuum of carea,b,e,f

  1. aFocus group discussion (FGD) hypertensive patients
  2. bFGD community health nurses
  3. cFGD clinical nurses
  4. dKey informant interview (KII) medical leadership
  5. eKII nursing leadership
  6. fKII cardiologist