The knowledge-practice gap: Evidence-based practice for acute stroke care in Ghana

A critical global health concern in the last few decades is the widened gap between what we recognized scientifically as best practice interventions and what patients actually receive in clinical settings. Despite the fact that the past two decades has witnessed a preponderance of new and more effective interventions for acute stroke care globally, uptake of such interventions is inadequate and remains largely inaccessible to stroke patients. To be specific, uptake rates in low-middle income countries (LMICs) is pervasively slow, notwithstanding the fact that these countries bear a greater proportion of the global stroke burden. Yet, research on the application of contemporary interventions for acute stroke care in these contexts has been limited. Contextualizing this from the theoretical standpoints of evidence-based practice and knowledge translation, the overall purpose of this thesis was to advance understandings on the extent to which proven interventions for acute stroke care are implemented in standard practice in Ghanaian hospital settings This thesis aimed to 1) examine hospital-based services for acute stroke care and the extent to which such services are consistent with international best practice guidelines for acute stroke care; 2) evaluate in-hospital mortality outcomes among acute stroke patients in Ghanaian hospitals; and 3) explore acute stroke care professionals’ views on the practical barriers to the provision of evidence-based care for acute stroke patients. This thesis comprised three separate but interlinked studies. The first was a multi-site, hospital based survey conducted in 11 referral hospitals (regional and tertiary/teaching hospitals) in Ghana among neurologists, physician specialists and general medical officers. A structured questionnaire was used to gather data on available hospital-based acute stroke services, which were then analysed descriptively. The second study was a retrospective cohort study which evaluated in-hospital mortality outcomes among consecutive acute stroke patients admitted to six referral hospitals, comprising a sample of 300 participants selected randomly, representing about 50 patients from each site. Both descriptive and inferential statistics were used to conduct the analysis. The final study involved a multisite in-depth, semi-structured interview conducted in the retrospective study sites, comprising a purposive sample of 40 acute stroke care professionals (neurologists, emergency physician specialist, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and dietitian) to explore potential barriers to acute stroke care. Thematic and grounded theory approaches were employed to analyse the data. Overall, the findings showed the availability of evidence-based services for acute stroke care were limited. Only one tertiary-teaching hospital had a stroke unit. Although aspirin therapy was administered in all hospitals, none of the hospitals surveyed offered thrombolytic therapy (thrombolysis). Although eight study sites reported having a brain computed tomographic (CT) scanning, only 7 were functional. Magnetic resonance imaging (MRI scan) services were also limited to only 4 hospitals (only functional in three) within the sample hospitals. Acute stroke care specialists, especially neurologists, were available in 4 of the study hospitals whilst none of the study hospitals had an occupational or speech therapists. The results further highlight inadequate health policy priority towards acute stroke care across the sample hospitals. Evidence from the retrospective study revealed that the delivery of acute stroke care remained variable and patient outcomes, mainly in-hospital mortality, were also higher and varied across the study sites by international comparisons. However, patients provided with aspirin recorded less in-hospital mortality. There was also insignificant variance in-hospital mortality across admitting wards. Hypertension was identified as a significant risk factor for in-hospital mortality. The qualitative interviews also identified four key potential barriers impeding the implementation of evidence-based acute stroke care. These included barriers at the patient (financial constraints, delays, socio-cultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across professional disciplines and hospitals. In summary, the findings highlight evidence of only limited application of contemporary acute stroke care interventions, and relatively high in-hospital mortality and morbidity rates, which may be due to multiple barriers to provision of acute stroke care. Decisive and critical decisions are thus required to increase political support for acute stroke care by developing relevant policy to support well-targeted interventions that improve uptake of new treatment options for excellent clinical outcomes, with the ultimate goal of closing the current evidence-practice gap in Ghana and potentially other LMICs.