Received: 5 September 2019  |  Revised: 6 December 2019  |  Accepted: 27 December 2019 DOI: 10.1111/hex.13027 O R I G I N A L R E S E A R C H P A P E R Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health- care professionals’ perspectives Leonard Baatiema PhD, Research Fellow1  | Ama de-Graft Aikins PhD, Professor2 | Fred S. Sarfo PhD, Senior Lecturer3,4 | Seye Abimbola PhD, Senior Lecturer5 | John K. Ganle PhD, Lecturer6 | Shawn Somerset PhD, Professor7 1Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Abstract Ghana Background and Objective: Efforts to improve the adoption of evidence-based inter- 2Institute of Advanced Studies, University ventions for optimal patient outcomes in low-/middle-income countries (LMICs) are College London, London, UK 3Kwame Nkrumah University of Science & persistently hampered by a plethora of barriers. Yet, little is known about strategies Technology, Kumasi, Ghana to address such barriers to improve quality stroke care. This study seeks to explore 4Department of Medicine, Komfo Anokye health professionals’ views on strategies to improve quality stroke care for people Teaching Hospital, Kumasi, Ghana 5School of Public Health, University of who had a stroke in a LMIC. Sydney, Sydney, NSW, Australia Methods: A qualitative interview study design was adopted. A semi-structured in- 6School of Public Health, University of terview guide was used to conduct in-depth interviews among forty stroke care pro- Ghana, Legon, Ghana 7 viders in major referral centres in Ghana. Participants were from nursing, medical, Faculty of Health, University of Canberra, Canberra, ACT, Australia specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical Correspondence Leonard Baatiema, NCDs Support Centre settings. A thematic analysis approach was utilized to inductively analyse the data. for Africa, Noguchi Memorial Institute for Results: A number of overarching themes of strategies to improve quality stroke care Medical Research, University of Ghana, P.O Box LG 581, Legon, Ghana. were identified: computerization and digitization of medical practice, allocation of Email: lbaatiema@noguchi.ug.edu.gh adequate resources, increase the human resource capacity to deliver stroke care, Funding information development of clinical guideline/treatment protocols, institutionalization of multi- The first author (LB) was a PhD Candidate funded under the Australian Catholic disciplinary care and professional development opportunities. These strategies were University International Students however differentially prioritized among different categories of stroke care providers. Scholarship Programme, and at the time the study was conducted. LB was also financially Conclusion: Closing the gap between existing knowledge on how to improve quality supported by the University's Faculty of of stroke care in LMICs has the potential to be successful if unique and context- Health Science Higher Degree Research Student Support Scheme during his specific measures from the views of stroke care providers are considered in develop- candidature. However, these funding bodies ing quality improvement strategies and health systems and policy reforms. However, did not play a role in the study design, data collection and analysis, results interpretation for optimal outcomes, further research into the effectiveness and feasibility of the and drafting of this manuscript or influenced proposed strategies by stroke care providers is needed. our decision to submit to BMC Family Practice. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors Health Expectations published by John Wiley & Sons Ltd Health Expectations. 2020;00:1–11. wileyonlinelibrary.com/journal/hex  |  1 2  |     BAATIEMA ET Al. K E Y W O R D S evidence-based care, health policy, low-/middle-income countries, quality improvement, quality of care, strategies, stroke, stroke care 1  | INTRODUC TION improve quality delivery of stroke care are essential. To this end, insights from stroke care providers have the potential to inform rel- Delivery of high quality and evidence-based health care is a major im- evant policy and quality improvement initiatives for stroke care with perative worldwide. Although major strides have been made in most more pronounced and sustainable clinical effects. countries with regard to developing high-quality health services to- wards better patient outcomes over the past two decades, major vari- ations in health-care delivery still exist and this is quite pervasive in 2  | MATERIAL S AND METHODS most health-care facilities in low-/middle-income countries (LMICs), where substandard care is provided to patients culminating in poor 2.1 | Aim patient outcomes.1,2 For example, it is estimated that up to 8.4 million deaths are recorded annually in LMICs as a result of compromised qual- This study aims to offer insights on clinically relevant strategies to ity of care.2 Within the context of stroke care, a paradoxical situation improving quality of stroke care in LMICs through a qualitative anal- exists where delivery of quality and evidence-based care for optimal ysis of stroke care providers’ recommended strategies, preferences, patient outcomes is relatively limited and poor in LMICs compared to and expectations to policy makers and health managers regarding high-income countries (HICs), although about 80% of the entire global quality improvement efforts for stroke care. burden of stroke is reported from LMICs.3 This burden has been largely attributed to the poor quality of care delivered in those settings and the low uptake of evidence-based practice.4-7 Findings from the recent 2.2 | Study design INTERSTROKE study further underscore the poor and limited access to optimal stroke care, leading to poor patient outcomes in LMICs.8 This study forms part of larger qualitative in-depth semi-struc- Similar to other resource-poor regions, recent research indicates tured interviews conducted over a six-month period (November access and delivery of quality and evidence-based stroke care in 2015-April 2016) to examine the knowledge-practice gap in pro- Africa is limited and often poor.3,4,8-10 Studies in Ghana,5 Senegal 6 viding evidence-based care for people who had a stroke in Ghana. and Congo 7 further exemplify the limited nature of access to quality The study was conducted in six major referral centres in Ghana. and evidence-based stroke care in LMICs. Efforts to improve uptake These comprised three tertiary-teaching and three regional hos- of better stroke care interventions to ensure optimal patient out- pitals drawn from the northern, middle and southern belts of comes in resource-poor settings have been persistently hampered Ghana. These sites were purposively selected to account for the by a range of barriers such as lack of skilled health personnel, pa- different geographical and socio-economic contexts across Ghana. tients’ lack of funds to meet health-care costs and inadequate health Where applicable, the study followed the Consolidated Criteria for infrastructure.4,11,12 In LMICs, health systems are often fragmented Reporting Qualitative Research (COREQ) checklist for reporting and underfunded, and there are rarely organized stroke care ser- qualitative research.17 vices.13 Compared to HICs,14 quality improvement initiatives for stroke care are rare in LMICs. Efforts to develop interventions and inform relevant policy to improve quality stroke care in LMICs are 2.3 | Participants often obstructed by limited contextualized evidence, a situation oc- casioned by the fact that most of the studies with insights on im- Forty acute stroke care professionals, comprising nursing, medical, proving quality of stroke care are reported from HICs.15,16 physician specialists and allied health, were recruited into the study There is consequently a significant deficit in our understanding (see Table 1). Participants were drawn from these various profes- of practical and contextually rich insights from stroke care provid- sional backgrounds and clinical settings to ensure rich and diversi- ers on strategies to closing the current widened knowledge-practice fied insights. They were each chosen because they play a key role gap in stroke care for improved outcomes in LMICs. To gain better in delivering stroke care and have made decisions or played supervi- understanding of how to improve the current level of care provided sory roles in relation to the delivery of stroke care. to people who had a stroke, it is critical to gain insights about what it takes to improve the quality of stroke care at the clinical interface. Importantly, being direct care providers for people who had a stroke, 2.4 | Recruitment and sampling and practically involved in almost every aspect of the care contin- uum within the organizational context of clinical care, perspectives Participant recruitment was conducted based on a standard pro- and experiences of health practitioners on practical strategies to tocol for recruiting participants for research in Ghanaian hospital BAATIEMA ET Al.      |  3 TA B L E 1   Demographic information of study participants rooms. An interview guide was designed and used to facilitate the (N = 40) conduct of interviews. The interview guide was open-ended in na- Number N Percentage (%) ture with follow-up prompts to seek clarity or gather further insights from participants. The interview guide was designed based on re- Sex view of relevant literature. Also, a number of stakeholders including Male 17 42.5 carers of people living with a stroke and stroke care experts were Female 23 57.5 consulted and their views incorporated in developing the content Age of the interview guide. The interview guide was later pre-tested 25-35 7 17.5 prior to the data collection and still further refined iteratively during 36-45 21 52.5 the data collection process to ensure questions were appropriately 46-55 9 22.5 framed, robust and had the flow to elicit adequate and appropriate 56+ 3 7.5 responses. The interview guide principally solicited the views of Years of professional experience stroke care professionals on practical and innovative strategies to 2-5 8 20 improve quality of acute stroke care. 6-9 17 42.5 Participants were not known to the researchers prior to the 10-15 12 30 study though it is likely some may be familiar with the first and sec- 15-20 3 7.5 ond authors given their previous work in some of the study sites. Overall, each interview lasted about 50 minutes. Interviews were Professional background audio-recorded alongside handwritten field notes. Nurse 20 50 Neurologist consultant 1 2.5 Neurologist 1 2.5 2.6 | Data analysis Emergency physician specialist 1 2.5 Medical officer/physician 9 22.5 All interviews were audio-recorded, transcribed verbatim by profes- Clinical psychologist 2 5 sional transcribers and anonymized. A thematic content analysis was Physiotherapist 5 12.5 consequently undertaken,18 using an inductive analytical approach Dietitian 1 2.5 where themes were generated based on recurrence and not on a prior framework. The first author (LB) read and re-read all transcripts on a line-by-line basis to establish familiarity with the content of the inter- settings. Formal invitation letters, ethics clearance letters and study views based on the grounded theory principle.19 Five transcripts were information sheets were sent to all study sites for approval either by first coded, and a coding framework was developed and subsequently the hospital administrators, heads of units and departments as ap- applied to all transcripts after reading several transcripts to ensure propriate prior to actual recruitment and conduct of the interviews. transparency and systematic coding of the interview transcripts. The The study employed a mixed sampling approach. First, a maximum coding process was aided by the NVIVO 10.0 (QSR International) pro- variation principle guided the sampling process to ensure recruited gram software. The framework was revised iteratively to ensure all participants had diverse clinical experiences, sex, age group, years relevant information was reported. All codes across the interviews of working experience, different professional ranks and covering were consolidated into key thematic categories related to strategies a range of schedules/roles in the stroke care continuum. Second, to improve acute stroke care. Patterns of codes from different partici- with the help of the hospital administrators or unit heads, a purpo- pants were compared to establish similarities and differences. A sec- sive sampling technique was utilized to recruit health-care profes- ond author (AdGA) cross-coded a sample of transcripts independently sionals who were directly involved or had expertize in the provision to establish reliability. A draft of the resulting categories according to of acute stroke care. Prospective study participants were briefed the key themes and interpretations was reviewed by two other authors about the study, and interviews were then scheduled for those who (AdGA and SS). Interview quotes from participants were used to illus- consented to participate in the study. Interviews were conducted trate or support key study findings and to highlight some underlying until theoretical data saturation was reached, a point where no new themes of participant perspectives. information emerged from subsequent interviews. 3  | RESULTS 2.5 | Data collection 3.1 | Basic participants’ characteristics Semi-structured, face-to-face in-depth interviews were conducted in English by the first author. Interviewing took place in various set- Overall, a total of forty20 participants were interviewed, and their tings including consulting rooms, hospital wards and conference basic characteristics are shown in Table 1 below. 4  |     BAATIEMA ET Al. F I G U R E 1   Framework of strategies for improving in-patient stroke care in LMICs Professional development opportunities Infrastructure Multidisciplinary and logistics care Improving Building Stroke partnership quality of awareness stroke care campaigns Human resources Development of for health standardized protocols Digitizing clinical practice 3.2 | Strategies for improving quality of stroke care in order to meet recommended treatment guidelines to ensure optimal clinical outcomes, there is the need to Participants proffered a wide range of strategies to support efforts ensure adequate supply of resources to ensure quality towards optimization of acute stroke care in the study settings. services to patient care. Seven overarching thematic strategies emerged from participant (Nurse, Participant 11). narratives (see Figure 1). Some participants (nurses) noted that the inadequacy or complete absence of such resources inevitably affected fidelity to standard 3.3 | Adequate allocation of medical logistics and treatment practice and procedures. Frequent stock-outs of essential infrastructure medical consumables were reported to lead to patients being required to purchase such consumables on their own, which sometimes results This theme was consistently emphasized by stroke care profession- in pronounced delays in treatment or increased length of stay. Limited als. Participants attributed the inconsistency, variations and poor or lack of patient monitoring for bedsores was reported to increase nature of care to limited or an apparent lack of medical logistics risk of pressure injuries or sores, thus affecting the quality of care and consumables. For instance, essential equipment such as blood provided, overall. Participants suggested that such health system de- pressure monitors and electrocardiograph machines were either not ficiencies and shortages could be addressed with increased political available, of poor quality, or worn out. A participant bemoaned the commitment to health care. Some suggested the private sector and state of limited medical equipment which often compromise delivery philanthropists could play a key role in augmenting the efforts of gov- of quality stroke care. ernment to ensure adequate supply of medical resources. Sometimes when the emergency ward is full, you can come here and find a suspected person with a stroke 3.4 | Human resources sitting on the wheel chair, there is no place, or a people who had a stroke comes in and urgently requires oxygen, Human resources, both in terms of numbers and quality of staff, was but other people are on oxygen and you cannot say that discussed and recommended extensively by participants. However, let me take patient A oxygen and give to patient B, so there was some divergence in views, with most of the medical doctors BAATIEMA ET Al.      |  5 (physicians) tending to suggest high-quality human resource capacity, stroke care were reported to be essentially non-existent and this whereas others focussed more on staff numbers. They believed access constrains efforts to provide quality of care and as well as under- to adequate and sufficiently motivated staff is more critical since to cutting efforts to adhere to evidence-based treatment guidelines, them the training to improve their competence and skills could later resulting in variations and inconsistencies in the delivery of care. be tackled. This according to them could take the form of better re- munerational packages, reward systems and scholarship opportunities Without treatment guidelines, there is no or little direc- for career development in stroke care Most of the participants also tion and consistency in the care we provide, especially expressed enthusiasm in providing quality stroke care but this ac- when there is no specialist or senior colleague to guide cording to them was often undermined by the limited number of staff the care we provide… available resulting in increased workload, stress and fatigue. In terms (Nurse, Respondent 17) of how to improve the current acute shortages in health workforce, participants proposed both the private and public sectors could play The second was a protocol to guide referral of people who had a a role, especially in recruiting and training more health staff in stroke stroke. According to participants, this is needed to ensure patients are care. The introduction of sub-specialties in stroke care in health train- referred to the appropriate point of care or health facility at the onset ing institutions may also help address the problem. All these could be of stroke: achieved through increased government allocation for the recruitment and training of health-care professionals on stroke care as poignantly Because there are no existing referral protocols, the pa- expressed by one participant in the study. tient will go to a clinic, the clinic will admit them before later making referral. Even though the patient attended Increased in staff supply will help address the deficit in a health facility, was that health facility the right place human resource capacity for stroke care especially spe- for the person to have gone? They went there, and they cialists with the requisite skills to provide or supervise could not handle it and they are now bringing it, and most the delivery of care to people who had a stroke. This will of the times these clinics will call to notify about a refer- help reduce the current workloads and ensure staff have ral case only when the conditions are deteriorating and ample space and expertise to deliver adequate and ap- because they don’t want mortalities recorded in their fa- propriate care cilities, they will just call in to inform us they are referring (Medical Officer, Respondent 3) a patient to our facility (Nurse, Respondent 7) Medical doctors mostly from the middle and northern belts of the study sites expressed critical views about the inequity and Medication dispensary protocol was also highly recommended by unfairness in the distribution of health-care providers in Ghana. nurses given the considerable delays they face at the hospital phar- Participants suggested the need for equitable distribution since they macies or drug dispensary points. Family members join long queues believe most health staff were concentrated in the urban cities of to purchase medications following prescription by a medical doctor. Ghana. They opined government needed to adopt pragmatic mea- Since most hospitals adopt a “first come, first serve policy”, they often sures to tackle this issue through a quota system to ensure every overlook family members with patients in critical conditions such as health facility has the requisite specialist staff to provide optimal and a stroke, and delays in accessing drugs potentially worsen the health quality stroke care. outcomes of patients. Our human resource problem in Ghana is a problem of You go there, and you see a long queue, and everybody inequitable distribution of healthcare providers. It is as is in a hurry, nobody knows which one is an emergency simple as that and yet there is lack of political will to fix case. At least if there was an existing protocol or policy this problem. to ensure particular patients require immediate atten- (Medical Officer, Respondent 2) tion should always be prioritized and served upon arrival. Better still, I think provisions should be made to ensure mini dispensary points are located in every ward 3.5 | Development of standardized protocols (Nurse, Respondent 31) The need for protocols, flow charts or stroke treatment algorithms to guide the continuum of care for people who had a stroke was sug- 3.6 | Computerization and digitization of gested by participants with three forms of standardized protocols medical practice emerging. A protocol or clinical guideline for treatment and man- agement of diagnosed stroke was a predominant theme suggested With difficulties in tracing patient records, medical history and to improve care. Accordingly, clinical guidelines and protocols for delays in transferring records from one unit/division of care to 6  |     BAATIEMA ET Al. the other, majority of the participants recommended the need to came in here were unaware it was a stroke, so public computerize all relevant medical records. In their view, this has awareness and education programmes for the public the potential to minimize significant delays in the treatment of to know some early stroke signs and symptoms will be acute stroke care where time is critical in the continuum of care. helpful. Some care providers, mostly nurses, believed this would facilitate (Medical Officer, Respondent 5) speedy review of medical histories and subsequently support ap- propriate design of care and discharge plans. They also indicated Despite consensus among participants on the need to intensify that adequate capacity building and training workshops to enable public awareness on early stroke signs and the need to seek medical them use technology to advance their clinical practice should be attention, participants were divided as to the form or strategy this prioritized. campaign should take. Some recommended channels such as televi- sion and radio, and other participants were of the view that stroke Electronic medical records should be introduced to en- awareness campaigns should take the form of community-based sure speedy access to accurate patient records. I am activities such as durbars, plays, or using outreach programmes. aware of other contexts in Ghana where clinical prac- Others suggested a combination of social media, traditional media tice has been digitised to make it possible for patients’ and use of community durbars to create such awareness at the pop- information to be shared between departments or ulation level. units among health professionals within seconds. This On the suggestion of using community-based durbars and drama, should be standardised in all clinical settings in Ghana one participant noted: in order to minimise delays in clinical decision making and potentially longer waiting times for patients will be Due to low literacy among many rural community mem- minimised bers, awareness creation on early stroke signs should (Medical Officer, Respondent 22) rather take the form of contextually-relevant campaigns in their own settings, language, and vocabulary. This A few participants however expressed reservations about the will have more impact than rolling out a one-size-fits all underdeveloped nature of existing medical technology and Internet media campaign… connectivity services. Accordingly, this has the tendency to delay de- (Nurse, Respondent 35) livery of care in the event of a total blackout or Internet connectivity problems. Some were apprehensive, noting that any loss of patient Although not a widely expressed view, a cross-section of par- electronic information without any form of backup will have dire con- ticipants opined a key point in relation to rolling out public educa- sequences for patient care. tion events on early stroke signs and symptoms. Accordingly, public awareness campaigns on the early signs and symptoms of stroke Yes, but you know applying technology in medical prac- could be mainstreamed into the health-care system where health- tice is yet to be developed in this part of the world despite care professionals are required to undertake targeted public edu- considerable boom in technological advancement glob- cation on stroke during consultancy, in-patient care or out-patient ally. Internet connection and power supply is erratic in visits for people with high risk of stroke. This was strongly empha- this part of the world, and this doesn’t support digitiza- sized by participants as a short-term measure in light of the lack of tion of medical practice in this part of the world government support for public education for stroke. (Physiotherapist, Respondent 15) 3.8 | Institutionalize multidisciplinary care team 3.7 | Stroke awareness campaigns A key feature of evidence-based stroke care is the delivery of Most participants interviewed agreed there was a need for public care by a multidisciplinary team care. Unsurprising, a consensus health campaigns to create awareness on early symptoms and signs emerged among participants especially the allied health staff of a stroke which was observed to be quite poor. They intimated about the need to institutionalize this approach, which is currently that the majority of Ghanaians are not able to identify early stroke lacking in how care is delivered to people who had a stroke. As a signs and are unsure about immediate steps to take following early result, most of the allied health professionals suggested a need to signs and symptoms of a suspected stroke. This according to them ensure adequate measures to ensure care is provided by a mul- could be a plausible cause of patient delays in seeking care following tidisciplinary team. Participants emphasized the need for care stroke onset with most presenting late at emergency departments. plans, especially discharge care plans, to be developed by a multi- disciplinary team. The commentary below encapsulates a view un- Public awareness on early stroke signs and symptoms is derscoring why delivery of care to people who had a stroke should very poor. Most of the patients and their relatives who be multidisciplinary: BAATIEMA ET Al.      |  7 The challenge that still remains is the fact that a patient relevant conference and workshop attendance would ensure stroke could even be discharged before your general rounds, care providers are current with the latest clinical guidelines. ……… so you go there and maybe there was a patient you attended to the previous day and when you get there the The sponsorship bit is essential because most of the re- patient is discharged so you missed out on that patient. It fresher training workshops or continuing education in is possible the patient will get home after discharge and any professional course or field is expensive in recent continue on a diet which may not inure to her/his bene- times and so we will need financial support from govern- fits, and in no time, the patient is on admission again with ment and hospital management to develop our profes- a similar or exacerbated condition sion further (Dietitian, Respondent 12) (Nurse, Respondent 40) Some participants were of the view that though such teams existed Another had this to say: in their hospitals, they are not operationalized, do not hold regular meetings and rarely provide care as a multidisciplinary team. Regular I need it, because sometimes when you are on duty, and multidisciplinary team meetings were emphasized for facilities where some stroke cases arrive, then I realised I've forgotten such teams existed and were functional. The accounts of a participant some basic procedures, because I left the classroom for summarized this point: a very long time (Nurse, Respondent 16) I think it is important we meet as a team from the various units. Such team meetings should not be considered as a Others were of the view that opportunities for refresher and fault-finding meeting as this may discourage attendance. professional development workshops would ensure currency with It should be a platform for all to attend, bring out the contemporary clinical guidelines for stroke and other chronic condi- problems they face in providing care and solutions sought tions. In their views, such opportunities would enable them to learn to improve patient care. more about current best practices and new strategies to achieving (Nurse, Respondent 29) best clinical outcomes for patients. Related to this is internal staff education and training, which could be arranged during monthly In line with this, one participant recommended the need to exploit departmental meetings. This was viewed as a cost-effective way to available technological tools by creating e-platforms such as WhatsApp improve knowledge and skills in quality stroke care delivery. to promote collaborative or multidisciplinary care. The physiotherapy department has shared with our unit 3.10 | Building partnerships for stroke care in charge (head) a WhatsApp number so when a person improvement with a suspected stroke is admitted into our ward or any patient requiring the services of a physiotherapist, we The analysis also found that building partnership across disci- just WhatsApp them, provide the name of the ward, the plines, within and outside hospitals, including outside the country, patient bed number, his/her name and then they come featured prominently as a key strategy to improve the quality of promptly to attend to the patient. This should be encour- stroke care. Participants, mostly medical doctors, indicated a need aged and extended to other units within the hospital for care improvement partnerships or collaborations to make it (Physiotherapist, Respondent 19) possible to train staff on the provision of stroke care. In their view, such partnerships should be supported by the state, especially senior health managers and policy makers by actively exploring 3.9 | Professional development and training and sponsoring such partnerships. These partnerships should sup- opportunities port specialists from other well-developed health systems to visit and share skills, experiences and knowledge on stroke treatment Emphasizing limited knowledge and competence in providing quality and management. care for people who had a stroke, most participants recommended uninhibited access to professional development and training pro- I think government and our policy makers should begin grammes for health professionals who provide care for stroke and to prioritise support for partnership building between other NCDs. They regard this as a career development incentive and hospitals and health professionals to improve care. This acknowledged that although professional training programmes are is definitely a cost-effective measure to improve care and sometimes organized, they often lack financial support to participate safe lives. Specialist in teaching hospitals with well-es- in such training workshops. A recommendation was made for budg- tablished stroke care systems should be able to train etary allocation to sponsor health-care providers. Opportunities for staff from health facilities with less developed stroke care 8  |     BAATIEMA ET Al. systems. Exchange learning visits should be made possi- sustainable development goals have placed further importance on ble as this could make a significant difference in saving or this as a measure to build capacity in global health. Thus, the finding improving lives of people who had a stroke in relation to fostering partnerships and collaborations to improve (Medical Officer, Respondent 8) stroke care corroborates international best practice measures to improve care, especially in LIMCs where health-care capacity is Other participants stressed the need for partnerships across coun- often weak and limited in scope and quality. Within the context of tries especially linking countries with established stroke care systems stroke care, there is evidence of a previous partnership between a and those with less developed systems of care. team from the UK and their Ghanaian counterparts (Wessex-Ghana Stroke Partnership) which sought to build capacity of stroke care The opportunity to host stroke care specialists from professional in stroke care.25 This partnership has since led to stroke well-developed stroke care systems of the developed care professionals benefiting from professional capacity building op- world or even support local staff to travel there to un- portunities on stroke care (eg, managing continence, discharge plan- derstudy how stroke care is provided will offer fresh per- ning, improving mood, functional independence and swallowing) spectives to staff, offer new skills, information and ideas and overall improvement in the health-care systems for stroke care on how to manage stroke will be worthwhile in the beneficiary health facilities. Evidence from South Africa also (Medical Officer, Respondent 18) suggests a similar arrangement appears to show promise.26 A review also corroborates the present findings on the need to establish part- In summary, a diversity of views from different stroke care pro- nerships to improve care. The review highlights that beneficiaries of fessional was expressed in relation to providing optimal patient care. such exchange or partnership programmes benefit both personally Whilst some views were associated with specific categories of stroke and professionally where skills from such collaborations are often care professionals, most of the recommended strategies were held by applied to improve patients outcomes.27 most or all participants to be essential. Participants also emphasized the need for competency-based training in acute stroke care through professional development and training opportunities, particularly in areas such as diagnostic 4  | DISCUSSION algorithms for stroke, including the use of stroke scales, and other treatment protocols. Studies in HICs underscore this as part of mea- To our knowledge, the present study is about the first to report the sures to improve stroke care. For instance, the USA has prioritized views and perspectives of stroke care professionals on strategies to training on stroke care for staff in delivering evidence-based care improve the quality of acute stroke care in low-/middle-income clini- for optimal patient outcomes.14,28 Besides stroke care, advocacy cal settings. Overall, stroke care professionals recommended seven for competency-based refresher training for staff have increasingly contextually and clinically practical strategies to improve quality of been recognized as an essential tenet of efforts to strengthen the acute stroke care. The findings also highlighted a diversity of per- health-care system and improve the quality of care provided to pa- spectives on strategies to improving quality stroke care, reflecting tients in LMICs.29 Hence, the suggestion by participants for profes- the broad range of health-care professionals implicated in optimal sional development and competency-based training workshops is an care. Among the strategies underscored by participants are the imperative. need for provision of adequate medical infrastructure and logistics, A key strategy to improving quality of stroke care is ensuring computerizing clinical practice, development of standardized clinical adequate resources to support the delivery of care. Access to guidelines to direct delivery of care, promote multidisciplinary team medical logistics and infrastructure in LMICs is often limited, and care. The rest relate to support for staff professional development, this has been previously recognized to be a persistent issue.11,12,30 public awareness campaigns on early signs and symptoms of stroke, The findings from this study aligns with these previous studies on partnership-building to improve stroke care. the need to ensure adequate provision of medical consumables Overall, the proffered strategies respond to recent recommen- and infrastructure such as neurosurgical services, neuroimaging dations by the Lancet Neurology Commission on the need to have and laboratory services to support stroke care. Previous litera- locally based measures to effectively tackle the growing burden ture shows that human resources for health crisis has persisted in of stroke in LMICs.21 These findings largely corroborate previous LMICs over the past decades despite modest gains made to tackle scholarship on increasing the quality of care in other contexts. this through expanded competency-based training and mentor- First, knowledge exchange and partnerships between low-/mid- ship schemes.30-32 Despite this, the problem persists and has dle-income countries and high-income countries has emerged as a been highlighted as a major impediment to efforts to reduce the key global health strategy to build resources for health crises cur- growing burden of NCDs such as stroke.33 The views expressed rently experienced in most countries with underdeveloped health by participants about the limited health workforce to provide systems.22-24 Such collaborations are recommended as a strategy to optimal stroke care accentuate the centrality and pervasiveness promote the development of clinical skills especially among work- of this issue. This revelation by participants needs to provoke in- ers in less developed health-care systems from LMICs. The current terest within key stakeholders in finding sustainable solutions to BAATIEMA ET Al.      |  9 the problem. Recommendations by participants on the need for 5  | CONCLUSION adequate human workforce to support stroke care are consistent with similar recommendations in the past.30,34,35 These are issues In sum, despite growing interest to close the gap between existing which have also been noted in previous studies conducted in knowledge on how to improve quality of stroke care and standard HICs,36 suggesting the global dimension of the problem. clinical practice, LMICs still lag behind HICs in providing quality and Internationally, experts, consensus statements and stroke evidence-based stroke for optimal clinical outcomes. The present care literature have consistently emphasized the need to have a study revealed potential strategies to improve quality in stroke care multidisciplinary approach to standardize health care.13,14,20,37-39 delivery based on views from stroke care providers. These findings Participants in the present study also expressed similar need. As are relevant to inform and shape policy initiatives to improve quality noted by participants, e-platforms such as WhatsApp can serve of stroke care in LMICs. In light of a global search for practical and as an excellent channel to share information between stroke care contextual initiatives to improve uptake of evidence-based stroke professionals. This arrangement could potentially facilitate develop- care interventions, the recommended strategies to improve stroke ment of joint care plans for the patients, fosters better and effective care are timely. It is important for policy makers and health manag- communication. Evidence suggests the adoption of multidisciplinary ers to consider the recommended strategies in context vis-à-vis the team care for people who had a stroke is still limited in LMICs,4,11 different stroke care providers in developing quality improvement notwithstanding some sporadic evidence.40 initiatives. Any contrary action could potentially hinder or under- Medical or clinical practice is increasingly becoming digitized fol- mine processes to improve stroke care. To ensure prudent allocation lowing modern technological advancements. As a result, patient clin- and use of the limited resources for health in LMICs, future research ical information can be stored electronically and retrieved through needs to evaluate the effectiveness and feasibility of each of the the same means to support faster clinical decision-making. However, recommended strategies. Identifying the views of people who had a this revolution is more relevant to HICs where health-care systems stroke and carers regarding strategies to improve quality stroke care are well-developed with state-of-the-art medical infrastructure to should also be prioritized in future studies. support digitization.20,37 In LMICS, this is increasingly encouraged by stroke care researchers 38,39,41 though recent evidence shows up- ACKNOWLEDG EMENTS take is still quite limited.20 A study from Australia shows digitizing The authors duly appreciate the support received from the partici- patient clinical data can improve coordination of care and conse- pating hospitals and all study participants. quently enhances patient outcomes.42 Consistent with the findings from this study, the need for stroke CONFLIC T OF INTERE S T awareness campaigns in LMICs is increasingly being advocated by The authors declare that they have no competing interests. recent studies.43,44 Even among health-care providers in Africa, identifying early stroke symptoms can sometimes be a challenge at AUTHORS' CONTRIBUTIONS the population level.45 Improving the public's knowledge of stroke LB, SS and AdGA conceived and designed the study. AdGA. LB, JKG, risk factors, signs and symptoms of stroke is critical to improving SA and SSF analysed and interpreted the data. LB drafted the manu- the quality of stroke care. Without organized, coordinated and con- script and later revised after critical feedback from SS, AdGA, SSF, textualized approaches to educate the public, the full potential of SA, JKG. All authors have reviewed and approved the final manu- proven therapies for prevention or acute intervention will not be script for submission. realized. E THIC S The study protocol obtained and maintained ethical clearance 4.1 | Strengths and limitations from four institutional review boards (IRB). These comprised the University Human Research Ethics Committee (2015-154H) and The recruitment of participants in this study targeted only those with the Ghana Health Service Ethical Review Committee on Research key primary responsibility for stroke care, which may have biased the Involving Human Subjects (GHS-ERC: 11/07/15). Approval was also study towards a particular category of participants. However, the sought from the Committee on Human Research Publications and observed divergent views on strategies to improve care across the Ethics of the School of Medical Sciences of the Kwame Nkrumah different category of stroke care professionals imply a diverse set of University of Science and Technology and the Komfo Anokye perspectives on the issue. Thus, the inclusion of different stakehold- Teaching Hospital (CHRPE/AP/141/16) and the Institutional Review ers in the continuum of stroke care is considered a strength of the Board of the 37 Military Hospital (37MH-IRB IPN 035/2015). study. Some study limitations were also observed. Despite the inclu- Written consent was obtained from all participants who consented sivity of the study participants, the views expressed by participants to be interviewed. Written consent was obtained from all partici- may not be representative of the full range of views of all stroke care pants prior to each interview. Participants were not incentivized or providers and thus should be considered in interpreting the study provided with motivational packages for participation. With consent findings. from participants, all interviews were audio-recorded. 10  |     BAATIEMA ET Al. DATA AVAIL ABILIT Y S TATEMENT 19. Corbin JM, Strauss A. Grounded theory research: procedures, can- The data that support the findings of this study are available on re- ons, and evaluative criteria. Qual Sociol. 1990;13(1):3-21. 20. Cadilhac DA, Kim J, Lannin NA, et al. National stroke registries for quest from the corresponding author. The data are not publicly avail- monitoring and improving the quality of hospital care: a systematic able due to privacy or ethical restrictions. review. Int J Stroke. 2016;11(1):28-40. 21. Owolabi M, Johnson W, Khan T, Feigin V. 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