Australian Catholic University ACU Research Bank Theses Document Types 4-2018 The knowledge-practice gap: Evidence-based practice for acute stroke care in Ghana Leonard Baatiema Follow this and additional works at:https://researchbank.acu.edu.au/theses Recommended Citation Baatiema, L. (2018). The knowledge-practice gap: Evidence-based practice for acute stroke care in Ghana (Doctoral thesis, Australian Catholic University). Retrieved fromhttps://doi.org/10.4226/66/5b21f42ec554d This Thesis is brought to you for free and open access by the Document Types at ACU Research Bank. It has been accepted for inclusion in Theses by an authorized administrator of ACU Research Bank. For more information, please [email protected]. The Knowledge-Practice Gap: Evidence-Based Practice for Acute Stroke Care in Ghana This thesis is in total fulfilment of the requirements for the degree of Doctor of Philosophy (PhD) Leonard Baatiema B.A, MSc School of Allied Health, Faculty of Health Sciences Australian Catholic University April 2018 1 Declaration This thesis contains no material that has been extracted in whole or in part from a thesis that I have submitted towards the award of any other degree or diploma in any other tertiary institution. To the best of my knowledge, this thesis contains no material previously published by any other person except where due acknowledgement has been made in the main text of the thesis. I warrant that I have obtained, where necessary, permission to use any third-party copyright material reproduced in the thesis, and to use any of my own published work in which copyright is held by another party. All research procedures reported in the thesis received the approval of the relevant Ethics Committees, where necessary (see Appendix for ethics approval documents). This thesis contains three (3) original papers published in international peer-reviewed journals, one (1) accepted manuscript under review with minor revisions and another (1) manuscript prepared for submission. The ideas, development and writing of all the papers in this thesis were the principal responsibility of me, the PhD Candidate, under the supervision of Associate Professor Shawn Somerset, Dr Carina Chan, Dr Adem Sav, Dr George Mnatzaganian, Professor Ama de-Graft Aikins and Ms Judith Coombes. I collected, analysed, reported, interpreted and integrated the data from three separate studies of which this thesis is comprised of. I however received statistical advice in analysing data for the retrospective cohort study from Dr George Mnatzaganian (Associate Supervisor). I am the lead author in all the published (3) and unpublished (2) studies included in this thesis. So, I led in the selection of topics, writing of study aims, methodological design approaches in all the manuscripts with inputs from other co-authors. The extent of contribution of co-authors is outlined in the authorship statement in Research Portfolio document in the appendix section. However, I singularly authored chapters 1, 3 and 5 including the preface provided in each chapter and sections where published, submitted or complete manuscripts are incorporated. Signature: Date: 19-03-2018 2 Acknowledgements Without hesitation, my first thanks are given in glory to the Almighty God for being the solid force around me during my studies. My PhD journey has been marked with unexpected twists and turns, but God’s will reigned and saw me through successfully. A number of people have been instrumental in the successful completion of this thesis. Firstly, I acknowledge the immense role played by my primary supervisor, Associate Professor Shawn Somerset. To him, I say a big thank you for all your critical feedback, support, guidance, encouragement, career building opportunities, for consistently reposing confidence in me, for your academic mentorship on scientific writing, a move which eventually paid off in many unimaginable ways. Similarly, the supervisory and mentoring role of the other supervisors (Dr George Mnatzaganian, Professor Ama de-Graft Aikins, Ms Judith Coombes, Dr Carina K.Y. Chan and Dr Adem Sav) are acknowledged. Besides your critically useful feedback, a blend of your skills, personalities, strengths, expertise and constructive criticisms has helped to shape me into a better researcher. I wish to also thank and acknowledge the diverse support from my previous supervisors, Dr Michael E. Otim, Associate Professor Liz Mclnnes, Associate Professor Dominque Cadilhac and Professor Sandy Middleton. I duly appreciate your support and contributions in the course of this doctoral research programme. Next, I acknowledge and thank Professor Maree Johnson and her team (Office of the Associate Dean of Research, Faculty of Health Sciences), for the support enjoyed at every stage of my candidature. Importantly, the funding support from the Faculty Research Student Support Scheme (FRSSS) for Higher Degree Research students from Maree’s office provided me with considerable financial relief for overseas field research and aided a successful data collection. I also owe a great debt of gratitude to the administrators of the ACU International Students Scholarship package, especially the Graduate Research Office for making this funding package 3 available to support me complete this PhD programme. I regard this funding opportunity as an investment into my future career in public health and am aware that I would not have been able to commence this PhD without the funding. I acknowledge the inspiration and assistance enjoyed from Mr Anthony M Sumah, Dr Cintia Martinez, Dr Adam Salifu, Dr Tahiru A. Liedong, Dr Seye Abimbola and in particular Dr Franklin Obeng Odoom, who was a fountain of inspiration and encouragement in the entire course of this study. As well, my ACU colleagues and friends; Debra Philips, Julia Sterman, Olivia Lee, Susanna Gorman, Oyebola Fasugba and the NRI team; have my thanks for giving me your time, companionship and support during this period. I also wish to thank the office of the Director General of Ghana Health Service, the participating facilities under the Ghana Health Service and Ministry of Health who offered extensive support during the field data collection period, in particular to Dr Fred Sarfo, Mr Emmanuel Mwini, Mr Joseph Ali, Dr Augustina Charway Felli, Dr Erica Dickson, Dr Salia Suziema, Dr Jennifer Asamani, Dr Francis Wuobaar, Dr Hectoria Awekeya, Dr Frederick Paaga, Dr Jerry Paul Ninnoni, Dr Derek Tuoyire and Miss Esi Leeward Amissah. Without your incredible assistance, I would not have had a successful and exciting field data collection. This thesis has also benefited from the support, encouragement and prayers of my family so I offer thanks to my father and siblings (Louis, Linus and Diana) for their show of love, support and encouragement over the past years. In a very special way, I wish to affectionately thank my wife (Joana), and our two children (Stacy and Leo), for the immense sacrifices made while I pursued this PhD programme. Joana, you were my rock, counsellor, companion and encouragement in every stage of this thesis. You remained patient, tolerant and acted as my morale booster, especially during tough times. It is with gratitude and humility, I affectionately thank you. 4 Dedication With love, I dedicate this work to my late mum, Madam Theresa Kawalibayi, who made great sacrifices for me and my siblings but never lived to witness me rise to this academic pinnacle. 5 List of Abbreviations CDC: Centres for Disease Control and Prevention CT: Computed Tomographic HICs: High-Income Countries LMICs: Low-Middle Income Countries MRI: Magnetic Resonance Imaging WB World Bank NCDs: Non-Communicable Diseases SPSS: Statistical Package for the Social Sciences t-PA: Intravenous Tissue Plasminogen Activator WHO: World Health Organisation AMED: Allied and Complementary Medicine Database CINAHL: Cumulative Index to Nursing and Allied Health Literature ED: Emergency department FAST: Facial drooping, arm weakness, speech difficulties and time GRADE-CERQual: Confidence in the Evidence from Reviews of Qualitative Research ICU: Intensive Care Unit MeSH: Medical Subject Heading NINDS: National Institute of Neurological Disorders and Stroke PRISMA: Preferred Reporting Item for Systematic Reviews and Meta-Analysis 6 Abstract A critical global health concern in the last few decades is the widened gap between what we recognized scientifically as best practice interventions and what patients actually receive in clinical settings. Despite the fact that the past two decades has witnessed a preponderance of new and more effective interventions for acute stroke care globally, uptake of such interventions is inadequate and remains largely inaccessible to stroke patients. To be specific, uptake rates in low-middle income countries (LMICs) is pervasively slow, notwithstanding the fact that these countries bear a greater proportion of the global stroke burden. Yet, research on the application of contemporary interventions for acute stroke care in these contexts has been limited. Contextualizing this from the theoretical standpoints of evidence-based practice and knowledge translation, the overall purpose of this thesis was to advance understandings on the extent to which proven interventions for acute stroke care are implemented in standard practice in Ghanaian hospital settings This thesis aimed to 1) examine hospital-based services for acute stroke care and the extent to which such services are consistent with international best practice guidelines for acute stroke care; 2) evaluate in-hospital mortality outcomes among acute stroke patients in Ghanaian hospitals; and 3) explore acute stroke care professionals’ views on the practical barriers to the provision of evidence-based care for acute stroke patients. This thesis comprised three separate but interlinked studies. The first was a multi-site, hospital- based survey conducted in 11 referral hospitals (regional and tertiary/teaching hospitals) in Ghana among neurologists, physician specialists and general medical officers. A structured questionnaire was used to gather data on available hospital-based acute stroke services, which were then analysed descriptively. The second study was a retrospective cohort study which evaluated in-hospital mortality outcomes among consecutive acute stroke patients admitted to six referral hospitals, comprising a sample of 300 participants selected randomly, representing about 50 patients from each site. Both descriptive and inferential statistics were used to conduct 7 the analysis. The final study involved a multisite in-depth, semi-structured interview conducted in the retrospective study sites, comprising a purposive sample of 40 acute stroke care professionals (neurologists, emergency physician specialist, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and dietitian) to explore potential barriers to acute stroke care. Thematic and grounded theory approaches were employed to analyse the data. Overall, the findings showed the availability of evidence-based services for acute stroke care were limited. Only one tertiary-teaching hospital had a stroke unit. Although aspirin therapy was administered in all hospitals, none of the hospitals surveyed offered thrombolytic therapy (thrombolysis). Although eight study sites reported having a brain computed tomographic (CT) scanning, only 7 were functional. Magnetic resonance imaging (MRI scan) services were also limited to only 4 hospitals (only functional in three) within the sample hospitals. Acute stroke care specialists, especially neurologists, were available in 4 of the study hospitals whilst none of the study hospitals had an occupational or speech therapists. The results further highlight inadequate health policy priority towards acute stroke care across the sample hospitals. Evidence from the retrospective study revealed that the delivery of acute stroke care remained variable and patient outcomes, mainly in-hospital mortality, were also higher and varied across the study sites by international comparisons. However, patients provided with aspirin recorded less in-hospital mortality. There was also insignificant variance in-hospital mortality across admitting wards. Hypertension was identified as a significant risk factor for in-hospital mortality. The qualitative interviews also identified four key potential barriers impeding the implementation of evidence-based acute stroke care. These included barriers at the patient (financial constraints, delays, socio-cultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff, inadequate staff development opportunities), health professionals (poor 8 collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across professional disciplines and hospitals. In summary, the findings highlight evidence of only limited application of contemporary acute stroke care interventions, and relatively high in-hospital mortality and morbidity rates, which may be due to multiple barriers to provision of acute stroke care. Decisive and critical decisions are thus required to increase political support for acute stroke care by developing relevant policy to support well-targeted interventions that improve uptake of new treatment options for excellent clinical outcomes, with the ultimate goal of closing the current evidence-practice gap in Ghana and potentially other LMICs. 9