Wessex and Ghana Stroke Partnership March 2009

1. Wessex and Ghana  Stroke PartnershipMarch 2009 NESC � NHS Education South Central NESC � NHS Education South Central

2. Ghana

3. Background to Visit One week visit in March 2009 Liz Cullen � OT and Trainee Consultant Practitioner Louise Johnson � Physiotherapist and Trainee Consultant Practitioner Dr David Jarrett � Consultant, Portsmouth Hospitals Trust Sarah Easton � Portsmouth Community Stroke Rehabilitation Team Leader and SLT, PHT Hayden Kirk � Physiotherapist and Trainee Consultant Practitioner Anna Gould � Physiotherapist and Trainee Consultant Practitioner Background to the link. Funding for our visit. Aims of our visit.Background to the link. Funding for our visit. Aims of our visit.

4. Ghana Sub-Saharan Africa Total population 23 million Languages: English, Ga, Ewe and Twi Mixed colonial history; prominent in slave trade Gained independence in 1957 Culturally strong Presidential democracy Just north of equator Roughly same size as England Population 23 million Steady temperature of approximately 30 degrees day and 25 at night � rarely clear skies, with rainy seasons and �dusty� season Principal religions: Christian, Islam and African Traditional Dominant agricultural sector; small intensive mining; growing small traders, business men etcJust north of equator Roughly same size as England Population 23 million Steady temperature of approximately 30 degrees day and 25 at night � rarely clear skies, with rainy seasons and �dusty� season Principal religions: Christian, Islam and African Traditional Dominant agricultural sector; small intensive mining; growing small traders, business men etc

5. Ghana Current administrative areas are based on original tribes; many different languages Westernisation is leading to changes in diet and family structure 10 Regions � Accra is the smallest and most densely populated10 Regions � Accra is the smallest and most densely populated

9. Ghana and UK Facts (WHO, 2008)

10. Ghana Health Service Ghana Health Service: 5 levels National Regional District Sub-District Community Autonomous Teaching Hospitals Quasi-Government Institutions � e.g. Military Hospital, Police Hospital Private Providers NGO�s 60% of pop have adequate access to health facilities (1 hr travel) but increasing fees deter the poor. (WHO, 2006) Ghana Health Service � largest Ministry agency 5 levels of organisation National, regional, district, sub-district and local Autonomous teaching hospitals; private providers; Christian Health Association Accra � capital city where visit based � 4 government hospitals; Military Hospital; Teaching Hospital � Korle Bu Accra has almost 200 clinics, hospitals and maternity clinic This contrasts with relatively small numbers in the rural areas WHO 2004 - 3,240 doctors (2 per 10,000 pop); 20,000 nurses and 76 Physiotherapists; 2 SLT�s and no OTs Greater Accra first largest cause of death is Malaria, with stroke second In Ghana stroke is in the top 5 causes of death This reflects the changing public health status in the city �Westernisation� diet; exercise; smoking Ghana Health Service � largest Ministry agency 5 levels of organisation National, regional, district, sub-district and local Autonomous teaching hospitals; private providers; Christian Health Association Accra � capital city where visit based � 4 government hospitals; Military Hospital; Teaching Hospital � Korle Bu Accra has almost 200 clinics, hospitals and maternity clinic This contrasts with relatively small numbers in the rural areas WHO 2004 - 3,240 doctors (2 per 10,000 pop); 20,000 nurses and 76 Physiotherapists; 2 SLT�s and no OTs Greater Accra first largest cause of death is Malaria, with stroke second In Ghana stroke is in the top 5 causes of death This reflects the changing public health status in the city �Westernisation� diet; exercise; smoking

11. Ghana Health Service National Health Insurance Scheme estimated only 55% of population pay into this theoretically free to the �core poor� and those over 70 yrs old; annual charge from US$11 (�very poor�) � US$64 (�very rich�) for everyone else payments are not yet reaching the hospitals Covers basic health services Payment has to be confirmed before any service is provided � every bandage, medicine, x-ray etc NHIS introduced in 2003NHIS introduced in 2003

12. Ghana Health Service WHO (2004): 3,240 doctors (2 per 10,000 pop; 23 per 10,000 in UK) 20,000 nurses ( 9 per 10,000 pop; 128 per 10,000 in UK) 76 Physiotherapists 2 SLT�s no Occupational Therapists

13. Cultural Beliefs Principal Religions: Christianity, Islam, African Traditional Mix of Western Medicine and Traditional Beliefs Widely believed that stroke emanates from supernatural causes (demons and witchcraft) Often mixed treatment seeking behaviours Witch Doctors, Juju Men, Herbalists

14. Stroke in Ghana Chronic and non-communicable diseases, eg hypertension, stroke and diabetes, have become significant health problems in Ghana, (Aikins, 2007) Hypertension � national prevalence of 28.7% HIV � national prevalence of 3.2% 5th highest cause of death in Ghana 2nd highest cause of death in Greater Accra (second to Malaria) Limited organised care, either in-patient or out-patient Limited evidence of specialist education/support Diabetes prevalence is increasing 5th highest cause preceded by HIV/AIDS, malaria, LRTI�s, perinatal conditins Rise in alcohol and tobacco use and obesity; salt and fat in dietDiabetes prevalence is increasing 5th highest cause preceded by HIV/AIDS, malaria, LRTI�s, perinatal conditins Rise in alcohol and tobacco use and obesity; salt and fat in diet

15. Aims and Objectives Closely aligned to the Crisp Report on �Global Health Partnerships�: The NHS is to recognise its role as a global employer of healthcare staff The NHS to recognise the value of overseas training and experience for its staff Support to be provided for the scaling up, training and education for healthcare workers in developing countries

16. Hospital Visits Visited 2 main hospitals Korle Bu Teaching Hospital Ridge Regional Hospital Both a mix of old colonial and modern buildings All wards single sexed Evidence of company sponsorship and charity support in all areas Both hospitals were mix ofBoth hospitals were mix of

17. Korle Bu Hospital Large teaching hospital.Large teaching hospital.

23. Ridge Hospital Regional HospitalRegional Hospital

24. Mobil Ward � Ridge Hospital Myriam: Palliative Care We met Myriam during a ward round on one of the general medical wards. Myriam is 82 and has a previous history of stroke. She was admitted nearly four weeks ago with a further stroke leaving her unable to move, speak or swallow. She was drowsy most of the time. She had been sustained by nasogastric feeding but there had been no improvement. Her family were trying to find the necessary funds for a CT brain scan. There had been no discussion with her family of neither her poor prognosis nor the possible need for palliative care. Medical staff felt such discussions would be perceived by patients and families as foretelling and perhaps causing clinical decline. Myriam: Palliative Care We met Myriam during a ward round on one of the general medical wards. Myriam is 82 and has a previous history of stroke. She was admitted nearly four weeks ago with a further stroke leaving her unable to move, speak or swallow. She was drowsy most of the time. She had been sustained by nasogastric feeding but there had been no improvement. Her family were trying to find the necessary funds for a CT brain scan. There had been no discussion with her family of neither her poor prognosis nor the possible need for palliative care. Medical staff felt such discussions would be perceived by patients and families as foretelling and perhaps causing clinical decline.

26. Francis: Feeding Francis appeared to have suffered a large stroke (probable TACS) and had been an inpatient at Ridge Hospital for one week. Like many of the patients Francis was nursed flat in bed and had not been sat upright or sat out since admission. Francis was being fed via NG-tube, which had been pulled out and then re-sited on the morning of our visit. We were informed that the standard procedure for NG-feeding was for water and soup, plus crushed medications, to be poured down the tube, often by the family. A joint clinical session between the visiting and local teams stimulated discussion about optimal positioning for NG feeding, and the possibility of physiotherapists and nurses working together to achieve this. Francis: Feeding Francis appeared to have suffered a large stroke (probable TACS) and had been an inpatient at Ridge Hospital for one week. Like many of the patients Francis was nursed flat in bed and had not been sat upright or sat out since admission. Francis was being fed via NG-tube, which had been pulled out and then re-sited on the morning of our visit. We were informed that the standard procedure for NG-feeding was for water and soup, plus crushed medications, to be poured down the tube, often by the family. A joint clinical session between the visiting and local teams stimulated discussion about optimal positioning for NG feeding, and the possibility of physiotherapists and nurses working together to achieve this.

29. Stroke in Ghana Pre-payment required for everything No CT scan � strokes often �misdiagnosed� No feed for n-g�s � soup and water by families ��3� per outpatient physiotherapy session Discussion of palliative care perceived as �foretelling� clinical decline; contrast of doctors and herbalists Dependence on �high tech� and equipment Limited multidisciplinary working Dependence on CT scans � one family still trying to raise money 4 weeks post stroke � gain? Not just soup and water poured down n-g tube � all medications crushed. No awareness of thickener � yet aware of high number of chest infections in stroke and readily spoke about aspiration No chairs on wards � patients in bed Splints made in out patients � suitability? No equipment such as hoists, slide boards, commodes on ward Really pleased with slide sheets donated Balance between financial ability and clinical decisions � eg gent attending out patients � clinical reasoning versus ability to pay Balance between cultural drive and clinical rehabilitation � eg the same gent able to functionally achieve most activities of daily living versus his family�s support and �care� for him Dependence on CT scans � one family still trying to raise money 4 weeks post stroke � gain? Not just soup and water poured down n-g tube � all medications crushed. No awareness of thickener � yet aware of high number of chest infections in stroke and readily spoke about aspiration No chairs on wards � patients in bed Splints made in out patients � suitability? No equipment such as hoists, slide boards, commodes on ward Really pleased with slide sheets donated Balance between financial ability and clinical decisions � eg gent attending out patients � clinical reasoning versus ability to pay Balance between cultural drive and clinical rehabilitation � eg the same gent able to functionally achieve most activities of daily living versus his family�s support and �care� for him

30. Physiotherapy Physiotherapy training course started in 2002 at the University of Accra Physiotherapy provision has been developing since Modern facilities � funded through a joint initiative between the Dutch and Ghanaian Governments

37. Physiotherapy Emanuel: Long Term Care Emanuel was attending physiotherapy in the outpatient department at Korle Bu Hospital. He had suffered a stroke approximately a year previously, and had made a good recovery. He mobilized well with a walking stick and had good movement in his upper limb. We spent some time assessing Emanuel�s abilities and talking to him about his goals for therapy. He expressed that he would like to be able to �use his arm more�. We talked about what he did and didn�t already manage to do at home, but it was difficult to establish specific goals. Emmanuel lived with a very caring family, who appeared to do a lot for him � including assisting with personal care and even feeding him, although he would be able to do much of this himself with little problem. There appeared to be an interesting division between the patients expressed goals, his families and the therapists approach to rehabilitation � the two were not allied and we wondered whether establishing patient goals formed a part of the therapy assessment. There may be many complex reasons for this division, not least the cultural beliefs towards illness, payment for therapy and societal roles. However, therapists did tell us that they often found it difficult to motivate patients to take ownership of their rehabilitation. Managing patient expectations, promoting self management and setting patient centered goals is something that therapists find equally challenging in the UK. Emanuel: Long Term Care Emanuel was attending physiotherapy in the outpatient department at Korle Bu Hospital. He had suffered a stroke approximately a year previously, and had made a good recovery. He mobilized well with a walking stick and had good movement in his upper limb. We spent some time assessing Emanuel�s abilities and talking to him about his goals for therapy. He expressed that he would like to be able to �use his arm more�. We talked about what he did and didn�t already manage to do at home, but it was difficult to establish specific goals. Emmanuel lived with a very caring family, who appeared to do a lot for him � including assisting with personal care and even feeding him, although he would be able to do much of this himself with little problem. There appeared to be an interesting division between the patients expressed goals, his families and the therapists approach to rehabilitation � the two were not allied and we wondered whether establishing patient goals formed a part of the therapy assessment. There may be many complex reasons for this division, not least the cultural beliefs towards illness, payment for therapy and societal roles. However, therapists did tell us that they often found it difficult to motivate patients to take ownership of their rehabilitation. Managing patient expectations, promoting self management and setting patient centered goals is something that therapists find equally challenging in the UK.

42. Other Services No Occupational Therapy One Speech and Language Therapist; another arrived whilst we there. Have 2 students currently training in London Clinical Psychologist Dietitians Radiologists

44. The Workshops Pre visit questionnaire completed Approximately 70 attendees at each day Mixed professions and hospitals Presentations and group discussions Provided safe, neutral, multidisciplinary forum Provided time for reflection on current services

48. Group work/discussions � safe and neutral environmentGroup work/discussions � safe and neutral environment

49. Multidisciplinary � dietician addressing her colleaguesMultidisciplinary � dietician addressing her colleagues

50. Prof Narety � Chief Exec expressing his support for organised stroke careProf Narety � Chief Exec expressing his support for organised stroke care

51. HelpAge Ghana

52. Patient walking to get to day CentrePatient walking to get to day Centre

54. Staffing � Amy (retured nurse), Ebeneezer, some medical imputStaffing � Amy (retured nurse), Ebeneezer, some medical imput

55. Medical reviews. Donated drugs.Medical reviews. Donated drugs.

59. HelpAge Ghana Post stroke � limited out-patient services Only private care and equipment provision HelpAge Ghana provides vital support to stroke survivors at a Day Centre and with home visits by Amy a retired nurse Some people post stroke walk up to 45 minutes each way to attend Vital service for nutritional, medical and psychological support

60. Home Visit Home visit - reginaHome visit - regina

61. Support from familySupport from family

62. Home environementHome environement

63. Our Learning An opportunity to look at the wider issues of stroke care in developing countries � at both clinical and strategic levels. An intense leadership and team working experience � for example the mix of medicine, culture and religion required considerable understanding and adaptability Similarities in health services financial constraints, far more overt in Ghana greater demand than capacity, huge unidentified need in Ghana, especially in the community

64. Outcomes of the Visit Planned development of a stroke unit in Korle Bu Hospital, with consistent staff to enable the development of stroke specialist skills and expertise Planned improvement in community services, initially involving community health nurses Awareness of stroke as a specialism was raised, with greater multidisciplinary working and cross site development Aim to have stroke unit in Korle Bu in 6 months � when current wards move into new build releasing spare ward capacity. One male and one female ward identified Awareness that community services extremly limited at present, but plan to develop current community nurses as resource at present Awareness of travel and equipment implications in this development Awareness that Ghana could develop centre of excellence to be accessed by other countries in west, central Africa Recognition at the time of our visit that sign up from the highest authority was requisite to this development if it is to be implement in the most sustainable way Aim to have stroke unit in Korle Bu in 6 months � when current wards move into new build releasing spare ward capacity. One male and one female ward identified Awareness that community services extremly limited at present, but plan to develop current community nurses as resource at present Awareness of travel and equipment implications in this development Awareness that Ghana could develop centre of excellence to be accessed by other countries in west, central Africa Recognition at the time of our visit that sign up from the highest authority was requisite to this development if it is to be implement in the most sustainable way

65. The Future��.

66. Acknowledgments Dr Claire Spice and Dr Jane Williams (UK) All of the staff and patients in Ghana who showed us great kindness and gave willingly of their time, and in particular: Dr Hetty Asare, Dr Albert Akpalu Professor Nartey HelpAge Ghana NHS Education South Central British Medical Association Humanitarian Fund