Background
Theoretical issues
Methods
Setting
Study design
Study population
Sampling
Situation | Sampling procedure | Recruitment Strategy/ Inclusion Criteria |
---|---|---|
Out-patient units with designated clinic days for patients with a particular CNCD | Accidental sampling | Exit strategy was used to recruit patients after receiving care |
Out-patient units where several health conditions were presented including those that the study was not interested in | Purposive sampling | Exit strategy was used to recruit patients after receiving care |
In-patient units/departments which had several patients | Purposive sampling | • The nurse in charge helped to identify patients with CNCDs of interest to the study using patients’ registers • Patients who were active/stable, could communicate clearly, and not in pain/discomfort were recruited |
Patients with co-morbidities | Purposive | • Patients with comorbidities of interest to the study were recruited for all the CNCDs they had. • Patients with comorbidities of interest to the study were recruited for all the CNCDs they had |
Health Professionals | Purposive | • Only health professionals managing CNCDs of interest to the study were recruited • Health professionals who had worked in the respective departments/unit for at least 6 months, managing the respective CNCDs were recruited |
Research team
Data collection
Trustworthiness
Reflexivity
Ethical issues
Data analysis
Results
Background characteristics of study participants
Variable | KATH | KBTH | BOTH HOSPITALS | ||||||
---|---|---|---|---|---|---|---|---|---|
Male% | Female% | Total%(n = 15) | Male% | Female% | Total %(n = 15) | Male% | Female% | Total%(n = 30) | |
Age | |||||||||
20–29 | 13.3 | 20.0 | 33.3 | – | 26.7 | 26.7 | 6.7 | 23.3 | 30.0 |
30–39 | 20.0 | 33.3 | 53.3 | 6.7 | 40.0 | 46.7 | 13.3 | 36.7 | 50.0 |
40–49 | 6.7 | 6.7 | 13.4 | 6.7 | 6.7 | 13.3 | 6.7 | 6.7 | 13.3 |
50–59 | – | – | – | – | 13.3 | 13.3 | – | 6.7 | 6.7 |
Level of formal education | |||||||||
Diploma | 20.0 | 13.3 | 33.3 | – | 6.7 | 6.7 | 10.0 | 10.0 | 20.0 |
1st degree | 13.3 | 46.7 | 60.0 | – | 79.9 | 79.9 | 6.7 | 63.3 | 70.0 |
2nd degree | 6.7 | – | 6.7 | 6.7 | – | 6.7 | 6.7 | – | 6.7 |
3rd degree | – | – | – | 6.7 | – | 6.7 | 3.3 | – | 3.3 |
Marital status | |||||||||
Never married | 26.7 | 13.3 | 40.0 | – | 20.0 | 20.0 | 13.3 | 16.7 | 30.0 |
Married | 6.7 | 46.6 | 53.3 | 13.3 | 66.7 | 80.0 | 10.0 | 56.7 | 66.7 |
Divorced | – | – | – | – | – | – | – | – | – |
Widowed | – | 6.7 | 6.7 | – | – | – | – | 3.3 | 3.3 |
Religion | |||||||||
Christianity | 33.3 | 60.0 | 93.3 | 13.3 | 80.0 | 93.3 | 23.3 | 95.5 | 93.3 |
Islam | 6.7 | – | 6.7 | – | 6.7 | 6.7 | 3.3 | 3.3 | 6.6 |
Ethnicity | |||||||||
Mole-Dagbani | 6.7 | – | 6.7 | – | – | – | 3.3 | – | 3.3 |
Ewe | 6.7 | – | 6.7 | – | 6.7 | 6.7 | 3.3 | 3.3 | 6.3 |
Akan | 26.6 | 60.0 | 86.6 | 13.3 | 66.7 | 80 | 20.0 | 63.3 | 83.3 |
Ga/Dangmegbani | – | – | – | – | 13.3 | 13.3 | – | 6.7 | 6.7 |
Occupation | |||||||||
Medical doctor | – | 6.7 | 6.7 | 13.3 | – | 13.3 | 6.7 | 3.3 | 10.0 |
Nurse | 20.0 | 53.3 | 73.3 | – | 60.0 | 60.0 | 10.0 | 56.7 | 66.7 |
Optometrist | – | – | – | – | 6.7.0 | 6.7 | – | 3.3 | 3.3 |
Physiotherapist | 13.3 | 6.7 | 20.0 | – | 20.0 | 20.0 | 6.7 | 13.3 | 20.0 |
Duration of practice (In years) | |||||||||
1–5 | 20.0 | 33.3 | 53.3 | – | 40.0 | 40.0 | 10.0 | 36.7 | 46.7 |
6–10 | 20.0 | 20.0 | 40.0 | 13.3 | 26.7 | 40.0 | 16.7 | 23.3 | 40.0 |
11+ | – | 6.7 | 6.7 | – | 20.0 | 20.0 | – | 13.3 | 13.3 |
Background characteristic | KATH | KBTH | BOTH HOSPITALS | ||||||
---|---|---|---|---|---|---|---|---|---|
Male% | Female% | Total%(n = 41) | Male% | Female% | Total%(n = 41) | Male% | Female% | Total%(n = 82) | |
Age | |||||||||
20–29 | 4.9 | 9.8 | 14.7 | 4.9 | 4.9 | 9.8 | 4.9 | 7.3 | 12.2 |
30–39 | 4.9) | 7.3 | 12.2 | – | – | – | 2.4 | 3.7 | 6.2 |
40–49 | 4.9 | 4.9 | 9.8 | 7.3 | 4.9 | 12.2 | 6.1 | 4.9 | 10.9 |
50–59 | 9.8 | 9.8 | 19.6 | 9.8 | 9.8 | 19.6 | 9.8 | 9.8 | 19.5 |
60+ | 14.5 | 29.2 | 43.7 | 26.7 | 31.7 | 58.4 | 20.7 | 30.5 | 51.2 |
Level of formal education | |||||||||
No formal education | 2.3 | 9.8 | 12.1 | 2.4 | 4.9 | 7.3 | 2.4 | 7.3 | 9.8 |
Primary | – | 9.8 | 9.8 | – | 2.4 | 2.4 | – | 6.1 | 6.1 |
Middle school/JHS | 17.1 | 14.6 | 31.7 | – | 4.9 | 4.9 | 8.5 | 9.8 | 18.3 |
SHS/O’level/A’level | 14.6 | 17.1 | 31.7 | 21.9 | 36.7 | 58.6 | 18.3 | 26.8 | 45.1 |
Tertiary | 4.9 | 9.8 | 14.7 | 21.9 | 4.9 | 26.8 | 13.4 | 7.3 | 20.7 |
Marital status | |||||||||
Never married | 2.4 | 12.2 | 14.6 | 4.9 | 7.3 | 12.2 | 3.7 | 9.8 | 13.4 |
Married | 34.1 | 19.6 | 53.7 | 41.5 | 34.1 | 75.1 | 37.8 | 26.8 | 64.7 |
Divorced | 2.4 | 12.2 | 14.6 | – | 2.4 | 2.4 | 1.2 | 7.3 | 8.5 |
Widowed | – | 17.1 | 17.1 | – | 9.8 | 9.8 | – | 13.4 | 13.4 |
Religion | |||||||||
Christianity | 36.6 | 53.7 | 90.3 | 36.6 | 46.3 | 82.9 | 36.6 | 50.0 | 86.6 |
Islam | 2.4 | 7.3 | 9.7 | 7.3 | 9.8 | 17.1 | 4.9 | 8.5 | 13.4 |
Occupation | |||||||||
Unemployed | 2.4 | 14.6 | 17.0 | 4.9 | 17.1 | 22 | 3.7 | 15.9 | 19.5 |
Retired civil servant | 2.4 | 7.3 | 9.7 | 14.7 | 2.4 | 17.1 | 8.5 | 4.9 | 13.4 |
Farmer | 9.8 | 4.9 | 14.7 | – | 2.4 | 2.4 | 4.9 | 3.7 | 8.5 |
Trader | 4.9 | 4.9 | 22.0 | – | 22.0 | 22 | 2.4 | 13.4 | 15.9 |
Driver | 7.3 | 17.1 | 24.4 | 2.4 | – | 2.4 | 4.9 | 8.5 | 13.4 |
Civil servant | 2.4 | 4.9 | 7.3 | 17.1 | 2.4 | 19.5 | 9.8 | 3.7 | 13.4 |
Artisan | 4.9 | 12.2 | 17.1 | 7.3 | 7.3 | 14.6 | 6.1 | 9.8 | 15.9 |
Ethnicity | |||||||||
Mole-Dagbani | 4.9 | 14.6 | 19.5 | 4.9 | 4.9 | 9.8 | 4.9 | 8 (9.8 | 14.6 |
Akan | 24.4 | 39.0 | 63.4 | 24.4 | 19.5 | 43.9 | 24.4 | 29.3 | 53.8 |
Ewe | 7.3 | 2.4 | 9.8 | 7.3 | 12.2 | 19.5 | 7.3 | 7.3 | 14.6 |
Ga/Dangme | – | 4.9 | 4.9 | 9.8 | 14.6 | 24.4 | 4.9 | 9.8 | 14.6 |
Nigerian | – | 2.4 | 2.4 | – | 2.4 | 2.4 | – | 2.4 | 2.4 |
Region of residence | |||||||||
Greater Accra | 2.4 | – | 2.4 | 36.7 | 43.9 | 80.6 | 19.4 | 21.9 | 41.5 |
Central | 2.4 | 2.4 | 4.9 | 7.3 | 4.9 | 12.2 | 4.9 | 3.6 | 8.5 |
Volta | – | – | – | – | 2.4 | 2.4 | – | 1.2 | 1.2 |
Eastern | – | 2.4 | 2.4 | – | – | – | – | 1.2 | 1.2 |
Ashanti | 29.3 | 36.6 | 65.9 | 2.4 | 2.4 | 4.8 | 15.9 | 19.5 | 35.4 |
Northern | 2.4 | 17.2 | 19.6 | – | – | – | 1.2 | 8.6 | 9.8 |
Upper East | 2.4 | – | 2.4 | – | – | – | 1.2 | – | 1.2 |
Upper West | – | 2.4 | 2.4 | – | – | – | – | 1.2 | 1.2 |
CNCDs of Patients | |||||||||
Eye cancer | – | 2.4 | 2.4 | 2.4 | – | 2.4 | 2.5 | 1.2 | 3.7 |
Prostate cancer | 4.9 | – | 4.9 | 4.9 | – | 4.9 | 4.9 | – | 4.9 |
Breast cancer | – | 2.4 | 2.4 | – | – | – | – | 1.2 | 1.2 |
Cervical cancer | – | – | – | – | 2.4 | 2.4 | – | 1.2 | 1.2 |
Leukaemia | – | – | – | 2.4 | – | 2.4 | 1.2 | – | 1.2 |
Asthma | 2.4 | – | 2.4 | 2.4 | 4.9 | 7.3 | 2.4 | 2.4 | 4.9 |
Diabetes | 2.4 | 7.3 | 9.8 | – | 2.4 | 2.4 | 1.2 | 4.9 | 6.2 |
Sickle cell | – | 4.9 | 4.9 | 2.4 | 2.4 | 4.9 | 1.2 | 3.7 | 4.9 |
Stroke | 4.9 | 9.8 | 14.6 | 4.9 | 7.3 | 12.2 | 4.9 | 8.5 | 13.4 |
Glaucoma | 7.3 | 2.4 | 9.8 | 9.8 | 7.3 | 17.1 | 8.5 | 4.9 | 13.4 |
Chronic kidney disease | 7.3 | 2.4 | 9.8 | 4.9 | 4.9 | 9.8 | 6.1 | 3.7 | 9.8 |
Chronic lung disease | – | 4.9 | 4.9 | – | 2.4 | 2.4 | – | 3.7 | 3.7 |
Hypertension | 2.4 | 4.9 | 7.3 | – | 7.3 | 7.3 | 1.2 | 6.1 | 7.3 |
Hypertension & Diabetes | 2.4 | 7.3 | 9.8 | 2.4 | 4.9 | 7.3 | 2.4 | 6.1 | 8.5 |
Hypertension, Diabetes & stroke | – | 2.4 | 2.4 | – | – | – | – | 1.2 | 1.2 |
Hypertension, Diabetes & glaucoma | – | 2.4 | 2.4 | _ | – | – | – | 1.2 | 1.2 |
Hypertension & Glaucoma | – | 4.9 | 4.9 | – | – | – | – | 2.4 | 2.4 |
Hypertension & Chronic kidney disease | – | – | – | – | 4.9 | 4.9 | – | 2.4 | 2.4 |
Hypertension & Prostate cancer | – | – | – | 2.4) | – | 2.4 | 1.2 | – | 1.2 |
Hypertension, Asthma & prostate cancer | – | – | – | 2.4 | – | 2.4 | 1.2 | – | 1.2 |
Hypertension & stroke | 2.4 | 2.4 | 2.4 | 2.4 | 2.4 | 4.9 | 2.4 | 2.4 | 4.9 |
Diabetes & breast cancer | – | – | 2.4 | – | 2.4 | 2.4 | – | 1.2 | 1.2 |
Thematic results
Main themes | Sub-themes |
---|---|
General management practices by health professionals | General assessment of patients’ conditions |
• Checking of vital signs | |
• Laboratory tests | |
• History taking | |
General education of patients | |
• On the state of their conditions | |
• On taking medications | |
• On proper storage of the medicines | |
Specific management practices by health professionals | Based on specific CNCD presented |
• Treatment depends on the CNCD presented | |
• Different medications and foods | |
Based on the stage of the condition at presentation | |
• Patients with early-stage presentation get life-saving interventions | |
• Patients with late-stage presentation only get treatment to ease pain and suffering | |
Self-management practices by patients | Self-restrictions |
• Diet restrictions | |
• Avoidance of triggers | |
Exercise | |
• Walking | |
Personal first aid | |
• Carrying out of warm water compression | |
Use of anthropometric equipment to monitor health status | |
• Monitoring of sugar level with a glucometer | |
Challenges in the management of CNCDs | Personal challenges of health professionals |
• Language barrier | |
• Work-related stress emanating from heavy workload | |
Institutional challenges of health professionals | |
• Poor utility supply | |
• Inadequate logistics | |
• Inadequate staff | |
• Inadequate motivation | |
• Inadequate infrastructure | |
• Inadequate in-service training | |
Patient-related challenges | |
• Financial challenges | |
• Social challenges |
Health professionals’ experiences with CNCD management
Laboratory testing also helped immensely to adequately understand the conditions presented by the patients. They argued that when the lab tests are conducted, they help to confirm the presence of the CNCDs in the patients. A nurse speaking on the tests conducted for patients in her department at KBTH noted:Well! we usually check some vitals such as blood pressure and that runs for every patient, whether you are hypertensive, or not. This is important and has to be done so that we have a baseline with which to work and manage your condition. We also take the weight and height for them.(Nurse, Female, 31 years)
History taking was also a key general CNCD management experience for the health professionals, as it gave them a clear understanding of disease onset and progression. History taking ensured effective management of the condition and a clear understanding of how they had been treating the conditions in the past.So, when they (patients) come, we screen to confirm what they have because some of them come and do not even know that they have other conditions … so we do everything (conduct a broad spectrum of tests) so that we are able to identify all possible conditions they have. So, we do the visual acuity test, gonioscopy…then we refer to the ophthalmologist.(Nurse, Female, 40 years)
Patient education was a major general CNCD management experience espoused by the health professionals. Education is an essential component in the general practices involved in the management of CNCDs, as it ensures that patients adhere to management directives required for improvements in health status [39, 40]. The health professionals in our study carried out this service by educating the patients on the state of their conditions, how to take their medications, and how to properly store the medications. On education about the state of the CNCDs, the experiences of the health professionals entailed educating the patients to appreciate the stage of their conditions. In this regard, the health professionals intimated that sometimes, patients come to the health facilities as relapsed cases and, in such situations, education was done to orient them on the fact that the CNCD had become chronic. This information then enabled the patients to appreciate the stage their conditions had reached so that they give the conditions more attention and seriousness. A nurse from KATH also noted that they normally took the patients to medical doctors who educated them on their conditions.So, the doctor will take the history which is about how the thing started. You ask a bit about the family history. …we the family specialists take information on social life, the social setting… whether he is coming from a rich or poor family.(Medical doctor, Male, 35 years)
So, when they (patients) come, we educate and send them to the doctor…to tell them about their condition, and the stage that it is, whether it is advance or at the early stage.(Nurse, Female, 30 years)
While the general management practices were performed by the health professionals irrespective of the CNCDs of patients, actual diagnosis and treatment depended mainly on the type of CNCD a patient presents. Medications given as well as foods to be eaten by patients varied based on the type of condition the patients presented. CNCD management practices carried out by the health professionals, for instance, varied when patients reported with either early-stage (normal) or late-stage (acute) conditions. Patients who reported early were given timely interventions including surgery to halt the level of deterioration of their conditions.We educate them on how to take the medications and also we inspect to make sure they follow the prescription. Those who do not follow the prescription are then educated again on the need to take them (medications) as expected(Nurse, Female, 30 years)
Sometimes, however, the patients delayed at home before reporting their conditions. When that happens, their conditions deteriorate before they report. The health professionals, in such situations, only provided them with management options meant to ease pain and suffering but not necessarily to improve their conditions.So, after they’ve been diagnosed, those (glaucoma patients) who report early and, therefore, have their optic nerves to be healthy and their field vision hasn't gone that bad, can undergo surgery and then the eye will do better after the surgery.(Nurse, Female, 34 years).
The general CNCD management services provided by the health professionals reflect the services provided to patients in the general healthcare system of Ghana. They are, thus, not so different from services provided to non-CNCD patients. Irrespective of health conditions presented to hospitals in Ghana, general practices like history taking and checking of vital signs make it possible for health professionals to identify the genesis of the problem and to identify appropriate interventions that could be preferred. In a social system where 19% of women and 9% of men have no formal education [41], it is sometimes a daunting task for health professionals to conduct general assessments such as history taking, as some patients find it difficult to appropriately describe their disease progress. It is, however, on these general assessments that CNCD-specific treatment options are based and this makes their conduct very imperative. In the management of CNCDs, specific management practices usually follow the general management services provided by health professionals to patients. It is at this point that tailor-made services are provided to the patients based on the conditions they present. The experiences of the health professionals regarding their CNCD management practices, thus, reflect the situation in the Ghanaian context and across the globe.…those (glaucoma patients) whose field vision is gone mainly because they came (reported) late and are just left with a tunnel vision, their optic nerve not that strong and their cornea not too good, the surgery will not be of benefit to them. So, what we do is to just give them medication to ease pain and suffering. That’s all.(Nurse, Female, 34 years)
Patients’ experiences with CNCD management
Aside from walking, self-restrictions were practised by most of the patients. They mainly stopped eating certain diets they considered unhealthy. The diet restrictions focused on the type of foods to avoid and time to avoid eating. Some patients, for instance, stopped eating late and no longer ate some foods they were eating prior to being diagnosed with their conditions. The patients also avoided known triggers of their conditions. An asthmatic patient who usually experienced episodes of her asthma due to dust from dirty fans and louvre blades as well as unprescribed medications, for instance, tried to avoid such triggers:With the exercise, I am able to do it. I am able to walk from here (KATH) to Tech (KNUST). Every day, I am able to walk about and I think it is good.(Patient, Female, 65 years)
The patients also used anthropometric equipment to monitor their health status at home. Some diabetes patients, for instance, bought glucometers which they used to check their glucose level at home and always reported at the hospital whenever they realised higher than normal blood glucose levels. Some of the patients also used first aid to ensure that their conditions do not degenerate before they report to the health facilities. One of the patients with sickle cell disease, for instance, resorted to the use of warm water compression whenever she was about to have a complication.Well! for me, mostly my attack comes as a result of dust especially the ones on fan and louvres, so, I try to avoid them... I don’t take in any medicine aside from the asthma medication that has been prescribed for me because they can cause an attack.(Patient, Male, 53 years)
As an LMIC, much of the efforts at managing CNCDs in Ghana, are in the hands of the patients. This is because the health system is usually overwhelmed with patients who are much more than health professionals (available to manage their conditions) and facilities to take care of all of them. Patients also spend most of their time at home and thus have to take charge of their own health while at home. The self-management practices realised in our study, to a large extent, reflect the popular avenues that patients use in the management of their conditions while at home. While patients use various forms of exercise, the main one realised in this study was walking, and this may be largely because the comparative majority of the study’s sample was above 50 years and cannot engage in the more vigorous exercises like jogging and running.I do take my own first aid before it gets serious. Whenever I start feeling pains, I use warm water compression to treat myself, take in my drugs and then rest a bit to see what happens, if it still isn't working, I have to rush to the hospital, and see a doctor.(Patient, Female, 43 years)
CNCD management challenges of health professionals
Personal challenges of health professionals
There were, however, instances where they called on colleagues who understood the languages to explain procedures, instructions, and conditions to the patients. Those who could not get colleagues to interpret resorted to the use of signs to communicate with the patients.Sometimes, there are some things you need to tell the patient or to know her exact need…But you will be talking to the patient and the patient can’t understand what you are saying. She will be talking to you and you can’t also understand what he or she is saying… So, the language barrier is a huge hindrance(Nurse, Female, 26 years)
Yes! there is (work-related) stress because the patients become many and at times, the treatment takes a long time and when you are treating patients at times, the treatment will not work well because maybe the cancer changed its course so we have to change the type of chemo drugs they are given.(Nurse, Female, 58 years)
Institutional challenges of health professionals
With regards to inadequate logistics, health professionals from both hospitals noted that CNCD management was constrained by the inadequacy of blood pressure (bp) monitors, prescription cards, tissue paper, continuation sheets, and equipment essential for the assessment, monitoring, and performing of management procedures were either inadequate or not available in some of the departments. CNCD management was also constrained by inadequate beds and stockout of medications and other consumables, and these challenges were more prevalent at KATH than KBTH. For instance, there are times that pharmacies lacked some medications which the health professionals felt should have been available:The water is not flowing. It can take like 5 to 6 days and it won’t flow. Right now, just go to the washroom and see. You’ll cry… And this place too is a female ward… basic handwashing technique is even poor because, how to get water is even a problem.(Nurse, Male, 28 years)
Due to lack of accommodation, many of the health professionals stayed very far from the hospital before coming to work daily. By the time they got to work, they were already exhausted. When they closed from work too, they had to enter commercial vehicles in the night (especially when running afternoon and evening shifts) to get home. This routine, therefore, negatively affected their productivity at work. We also found that from both facilities, infrastructure was inadequate. The health professionals explained that there was not enough space for service delivery and staff accommodation. A female health professional from KATH for instance noted that narrated their ordeal regarding the space in which her outfit operated. She said:Yea! there are some drugs that the pharmacy doesn’t have, so you have to go outside and buy them. So in this case, if the money is not available that means we can’t provide that management for the patient…So, the medicines unavailability especially when they are needed is a major challenge over here.(Nurse, Female, 26 years)
Even though several CNCD cases are reported at the various units/departments of the hospitals either on a referral or review basis daily, there was an inadequacy of health professionals to attend to such cases. This, therefore, negatively affected CNCD treatment timelines, quality of care, and overall management outcomes of patients. Many of the health professionals attributed the staff shortage to the lack of financial clearance to employ trained health professionals by the state.Hmm, yes! Our clinic is very small. Sometimes, when you call the patients they don’t get anywhere to sit. The patients too are many so if they can expand the place a little, it would help. When the patients are crowded on you like that it makes working difficult and uneasy.(Nurse, Female, 30 years)
Inadequacy of motivation was also a major challenge experienced by the health professionals in our study. While the health professionals expected to be given bonuses, end-of-year packages, and awards for working hard and attending to patients with CNCDs diligently, such motivations were generally not forthcoming. At KBTH, for instance, some of the health professionals noted that in the past, there were weekly and monthly bonuses that were given to them. About a year before our study, however, management of the facility stopped giving them such bonuses. At the end of the calendar year (in December), they were usually given some Christmas packages by the hospital management. The health professionals, however, complained that such packages were usually not adequate. For others, however, there was no such thing as staff motivation at their respective department/facilities as they had not experienced them since joining the hospital as workers.Staff shortage…we are understaffed. We are not getting new staff because there is no financial clearance for them to be employed so it is a problem…currently, people are getting to know more about physiotherapy...so you have more patients trooping in and wanting to be seen…so it’s a problem.(Physiotherapist, Female, 31 years)
In-service training was also not regularly organised for the staff. Some of the health professionals from both hospitals noted that workshops and conferences were not regularly organised to equip them with skills in the latest technologies and strategies for CNCD care. They, therefore, still use procedures that they considered outdated in the management of CNCDs.As for motivation, I don’t want to talk about it, so you see that I never talk about staff motivation? It will not be forthcoming so even if you say it, you just talk in vain.(Nurse, Female, 35 years)
Ghana is a multilingual country where there are over 80 local languages spoken [46]. Even though the official language is English, people usually prefer speaking in their local languages. The country also has a quite high illiteracy level, which makes it difficult for a significant proportion of the population to speak the English language. There are, therefore, challenges with language when it comes to inter-ethnic exchanges/interactions. The findings regarding the language barrier, therefore, posit with the Ghanaian context appropriately. As a developing country, Ghana has a health system that is mainly inundated by a myriad of challenges that militate against the effective delivery of health services. While health facilities strive to provide top-up training in the form of workshops and conferences, these are usually not enough due to challenges with funding for such programmes. The challenge of inadequate in-service training is, therefore, a systemic one. As a result of the growing population of Ghana, the generally higher life expectancy rates, as well as the availability of refined foods, coupled with poor eating habits, the number of people requiring CNCD services keeps increasing. This, however, comes at the backdrop that the country faces grave human resource and infrastructural deficits needed to meet the growing demand for CNCD services. The challenges of limited space and inadequacy of health professionals, as mentioned by health professionals in our study, therefore, reflect the systemic challenges inherent in the country’s health system.We don’t get that kind of regular in-service training or regular updates. So, that becomes a huge challenge. We still use the very out-moded procedures and all that…if you get specialists to organise programmes for us, it will help, but that doesn’t happen often.(Nurse, Male, 31 years)
Patients’ challenges with CNCD management
Financial challenges of patients
Sometimes, it’s financial constraints. Even the inability to cater for their transportation. So sometimes, they fail to come for review. So, I can say it’s about financial constraints.(Physiotherapist, Female, 27 years)
Even though the medications were expensive, some were not covered by the country’s social health insurance policy (the National Health Insurance Scheme [NHIS]) which would have made them more affordable to the patients:The medications are expensive. Sometimes, I inject insulin and when it gets finished, I can go and buy one medication like GHȼ (GH₵ 100 [GHȼ: The Ghana Cedi, is Ghana’s official currency). At times I am not able to buy and inject. So right now, my financial state is really down.(Patient, Male, 54 years)
Some of the patients were also not able to purchase anthropometric equipment for monitoring health at home due to financial challenges. A stroke patient from KATH, for instance, had this to say:All the drugs are expensive but are not on health insurance except some cases of breast cancer that we have insurance support for…not part of the health insurance medicines list...we have one medicine here and it is about GHȼ 6,000 but, it is not covered by the NHIS.(Nurse, Female, 34 years)
Yes! I have challenges with the machine that help me to walk. When I went to Atonsu Agogo, they (the health facility) had some device that is used in doing walking exercise. I would have preferred to have some to use at home but I don’t have enough money to buy it. It really disturbs me.(Patient, Female, 50 years)
Social challenges of patients
The health professionals also expressed concern that some patients usually took herbal medications while on the orthodox management for their conditions. Some also replaced the orthodox medications they were given with herbal medications completely. A nurse from KATH had this to say:I’m a teacher and I have to be in school at some particular times while am supposed to be here (at the hospital) too…The timing is one major problem I’m facing and it makes it difficult for me to come for review sometimes as indicated by the health workers.–KATH, Patient, Female, 26 years
A nurse from KBTH also gave instances where patients abandoned their medications to depend on herbal ones only to return with aggravated conditions. She posited:When they go home, they are told that they can take other drugs to heal them as well. They end up adding herbal medicines to the ones they have been given at the hospital. It makes it difficult for them to get better when that happens( Nurse, Female, 30 years)
In Ghana, a lot of the working population earn below the minimum wage [48], which points to the high rates of poverty within the adult population. When an individual becomes incapacitated in terms of being unable to work and earn an income due to a CNCD, it exerts a lot of financial constraints on the individual. Considering that medications and surgical procedures carried out in the management of CNCDs are quite expensive, it becomes difficult for them to afford. This, therefore, explains why the patients generally could not afford the cost of managing their CNCDs. With about 80% of Ghanaians relying on traditional medicine for primary health care [49], there is clearly a high level of trust in traditional medicine among the Ghanaian populace. This, therefore, explains why some patients abandoned their orthodox medications to focus on herbal ones.Yes, I know some patients who went for alternative care and came back in wheelchairs. There was this patient whom I knew was doing well and there was progress in his condition. Suddenly, I was not seeing the patient. So later, the patient came back in a wheelchair and according to the relative of the patient, they took some herbal concoctions and all that. Some also end up at prayer camps but come back worse off because they stop using the medicines we give them.(Nurse, Female, 35 years)