Reconceptualizing Community Pharmacy Practice in Ghana for Strengthened Primary Healthcare and Public Health

Despite the well-established role of skin-to-skin contact in reducing neonatal mortality, its implementation varies significantly across geographical regions, particularly in sub-Saharan Africa. Therefore, we estimated the prevalence of mother and newborn skin-to-skin contact at birth and investigated the factors associated with its practice in Ghana. We used data from the 2022 Ghana Demographic and Health Survey. The analysis included 3833 mother-child pairs. Data was analysed using Stata 17.0, with percentages and confidence intervals (CI) used to present the prevalence of mother and newborn skin-to-skin contact. We employed multilevel binary logistic regression models to examine factors associated with the practice of mother and newborn skin-to-skin contact. Overall, 67.2% [64.9 - 69.4] of mothers practised skin-to-skin contact. Delivery by caesarean section was associated with a decreased likelihood of mother and newborn skin-to-skin contact (adjusted odds ratio [aOR] = 0.04; 95% CI: 0.02, 0.06). Higher birth order (fifth or more) (aOR = 2.34, 95%CI: 1.13, 4.84) was significantly associated with increased odds of skin-to-skin contact. Women who had eight or more antenatal care visits were more likely to engage in skin-to-skin contact (aOR = 1.82; 95% CI: 1.04-3.21) than those with fewer than four visits. Women who delivered in a healthcare facility were more likely to practise skin-to-skin contact (aOR = 30.67; 95% CI: 18.93, 49.70) than those who delivered at home. Compared to women in the Western region, those in the Eastern (aOR = 2.85, 95%CI: 1.21, 6.73), Western North (aOR = 3.87, 95%CI: 1.60, 9.37), Ahafo (aOR = 3.09, 95%CI: 1.19, 8.02), North East (aOR = 4.44, 95%CI: 1.88, 10.50), Upper East (aOR = 3.67, 95%CI: 1.45, 9.31), and Upper West regions (aOR = 6.13, 95%CI: 2.33, 16.16) were more likely to practise skin-to-skin contact. Our study has shown moderate mother and newborn skin-to-skin contact practise in Ghana, with significant regional variations. Going forward, any initiatives by the Ghana Health Service, the Ministry of Health, or other organisations focused on maternal and neonatal health must consider the geographical context of their efforts and programme implementation. Enhancing skin-to-skin contact requires increased advocacy and health education during antenatal care sessions, alongside higher attendance at such visits. Additionally, advocating for hospital birthsand reducing the number of home births is likely to boost skin-to-skin contact practices in Ghana.

Clinical decision support software (CDSS) has been increasingly implemented to assist improved prescribing practice. Reviews and studies report generally positive results regarding prescribing changes and, to a lesser extent, patient outcomes. Little information is available, however, concerning the use of CDSS in community pharmacy practice. Given the apparent paucity of publications examining this topic, we conducted a review to determine whether CDSS in community pharmacy practice can improve medication use and patient outcomes. A literature search of articles on CDSS relevant to community pharmacy and published between 1 January 2005 and 21 October 2013 was undertaken. Articles were included if the healthcare setting was community pharmacy and the article indicated that pharmacy use of CDSS was part of the study intervention. Eight studies were found which assessed counselling, selected drug interactions, inappropriate prescribing and under-prescribing. One study was halted due to insufficient data collection. Six studies showed statistically significant improvements in the measured outcomes: increased patient counselling, 31% reduced frequency of drug-drug interactions (DDIs), reduced frequency of inappropriate medications in the elderly (2·2-1·8% patients) and in pregnant women (5·5-2·9% patients), and increased pharmacists' interventions for under-prescribed low-dose aspirin (1·74 vs. 0·91 per 100 patients with type 2 diabetes) and over-prescribed high-dose proton-pump inhibitors (PPIs) (1·67 vs. 0·17 interventions per 100 high-dose PPI prescriptions). Most studies showed improved prescribing practice, via direct communication between pharmacists and doctors or indirectly via patient education. Factors limiting the impact of improved prescribing included alert fatigue and clinical inertia. No study investigated patient outcomes and little investigation had been undertaken on how CDSS could be best implemented. Few studies have been undertaken in community pharmacy practice, and based on the positive findings reported, further research should be directed in this area, including investigation of patient outcomes.

To describe the provision of patient services through community pharmacies in the UK, with particular reference to England, and to explore the research evidence and policy developments for enhancing the contribution of community pharmacy to primary care and public health. In the UK, National Health Service (NHS) pharmaceutical services are delivered under contract by privately owned community pharmacies. In England, a new 3 tier structure for pharmaceutical services was introduced in 2005 comprising essential, advanced, and enhanced-level services. All NHS pharmacies must deliver 7 essential pharmaceutical services and provide evidence that they meet the requirements of a comprehensive quality assurance framework. In the first year of the contract, around 40% of pharmacies were accredited to undertake medicine use reviews, the first advanced-level service to be implemented. Meanwhile, up to 25% of pharmacies provide a variety of enhanced-level services; the most common of these is supervised administration of methadone as well as support programs for patients quitting smoking. New legislation is being introduced that will accomplish the following: allow pharmacists to acquire independent prescribing rights, require pharmacy technicians to be licensed, necessitate that both pharmacists and pharmacy technicians periodically demonstrate their continuing qualification to practice, and introduce the concept of the "responsible pharmacist" to the operation of community pharmacies. Community pharmacy is now being recognized by the government as a mainstream contributor to primary care and public health. The current priority is to integrate services provided through community pharmacies into programs provided by other primary care professionals, through strengthening information technology and contractual arrangements. While major changes to the regulation of the pharmacy workforce are occurring, the quality management of community pharmacy services merits further attention. The new NHS pharmacy contract and current legislative changes provide a basis for community pharmacy to become fully integrated into NHS long-term care and public health programs.

Public health qualifications, motivation, and experience of pharmacy professionals: exploratory cross-sectional surveys of pharmacy and public health professionals

Innovations

BackgroundEvidence-based clinical practice is an inherent component of mental health professional practice in developed countries. However, little is known about professional perspectives of evidence-based practice in mental in developing countries such as Ghana. This paper describes the processes involved in the delivery of best practice in Ghana. The paper reports on a realistic evaluation of mental health nurses and allied health professionals’ views on the evidence-based therapeutic process in Ghana.MethodsA purposive sample of 30 mental health professionals (MHPs) was recruited to participate in semi-structured, in-depth interviews. Thematic analysis was used to analyse the data. A program theory of Context + Mechanism = Outcome (CMO) configuration was developed from the analysis.ResultsThe thematic analysis identified two contexts, mechanism and outcome configurations (themes): 1) technical competency stimulates evidence-based mental health services, and 2) therapeutic relationship building ensures effective interaction. The study demonstrates that contextual factors (technical competencies and therapeutic relationship building) together with mechanisms (intentional and unintentional) help to promote quality in mental health service provision. However, contextual factors such as a lack of sign language interpreters yielded unintended outcomes including barriers to communication with providers for consumers with hearing impairment and those from linguistic minority backgrounds.ConclusionGovernment stakeholders and policymakers should prioritise policies, periodic monitoring and adequate financial incentives to support the mechanisms that promote technical competence in MHPs and the building of therapeutic relationship.

The Need to Invest in Community Pharmacy Practice

Has traditional medicine had its day? The need to redefine academic medicine

While the role of evidence-based public health in improving health outcomes is frequently touted, there remains a dearth of research examining the use of evidence in public health service particularly in low- and middle-income countries. Therefore, the aim of this research was to examine the use of evidence in local public health service in Ghana, a lower middle-income country. Semi-structured in-depth interviews were conducted with local health managers from 11 District Directorates of Health in Ashanti Region. Three organising themes emerged from the interview transcripts: understanding of evidence-based public health; the process of using evidence; and the value of evidence in public health practice. The study suggests that though evidence-based practice was not new to the local health managers, its application was very low. The process of using evidence commenced with making a decision about the direction of a programme which had been already prioritised and planned by other high-level actors and then various sources of information, including available research evidence, were used to justify the decision. The study has revealed that there is an urgent need for pre-service and in-service training programmes that build and maintain common skill sets and language among local public health practitioners in Ghana to accomplish evidence-based public health goals. Similarly, giving local health managers flexibility to prioritise and make decisions would result in increased uptake of evidence in local public health service.

The practice of herbal medicine is the most prevalent form of traditional medicine or complementary and alternative medicine utilized in many countries across the globe. This study assesses the factors influencing the use and preference for herbal medicines compared to orthodox medicines among clients visiting some selected herbal units in the Kumasi Metropolis operating under the Ghana Health Service. A cross-sectional study was conducted. Primary data was collected from 413 participants using semi-structured questionnaires. Convenience sampling technique were used to select the participants. Results indicated that 80.90 % of the respondents interviewed preferred herbal medicines to orthodox medicines. Factors influencing this preference were occupation, nature/severity of condition and cost of certified herbal drugs dispensed at the herbal unit. Also, respondents sought the services of the herbal unit for conditions which orthodox treatment outcomes are poor. The overall cost of certified herbal products prescribed at these units were considered as affordable by participants. Herbal medicine is preferred compared to orthodox medicine by patients utilizing the services of the herbal unit at government hospitals within Kumasi Metropolis.

Act for the future of community pharmacy

Partnerships are increasingly critical to achieve the mission of public health. We sought to understand the levers and tools that states use to better connect public health and primary care in efforts to strengthen public health. We reviewed literature focused on collaborative or integrative efforts between primary care and public health and examined strategies employed by 4 innovative states: North Carolina, Oregon, Rhode Island, and Washington. Using a purposive convenience sample, we conducted semistructured interviews with 17 state experts from January to March 2023. We asked leaders to describe their approaches to data sharing, communication, and systems change that could be adopted or adapted by other states interested in better connecting primary care and public health systems. We recorded and coded interviews. Seventeen state leaders from North Carolina, Oregon, Rhode Island, and Washington. Key experiences, strategies, policy levers, and lessons for integration or collaboration between primary care and public health sectors, both common and divergent, across the states. State activity can be categorized by 3 actions: (1) endeavors to support relationship building, both formal and informal; (2) efforts to employ coordinating bodies and champions to ensure all necessary actors are included in planning and communications with clear roles; and (3) approaches to identifying and elevating essential system elements and the change levers to support them. The integration is built primarily on the well-resourced medical care system rather than the public health system. States are engaged in creative approaches to collaboration between public health and primary care. Building blocks include backbone organizations, leadership training programs, payment reform spheres, interoperable data platforms, and intentional efforts to build relationships. Collaboration between primary care, public health, and community-based organizations is an opportunity to strengthen public health systems while staying focused on improving the public's health.

Wahlbeck's paper 1 provides a succinct and accurate overview of the public health approach to global mental health. Conceptually, public health incorporates not just evidence-based interventions from high-income countries, but also significant emphases on positive behavioral health, prevention, recovery, and social, cultural and environmental factors. Expanding global mental health to include positive behavioral health – and therefore all people – offers the advantage of attention to developmental needs, resilience, prevention, and recovery 2. The behavioral health field has ignored these issues and the related empirical research findings for too long. Relatedly, shifting from “mental health” to “behavioral health” could underscore the broad focus on healthy behaviors rather than a narrower focus on mental illness. As one ramification, mainstreaming behavioral health to the entire population may reduce stigma for those who experience the most severe disabilities. The practical implementations of the Movement for Global Mental Health have been criticized extensively 3. Despite its holistic and laudable rhetoric, implementation attempts have largely involved an expansion of Western evidence-based biomedical or psychological interventions delivered via lay health workers and have not been sensitive to cultures and communities. Local communities often object to the imposition of Western models of individual mental illness when the problems are widespread, the culture is not so individualistic, and behaviors are obviously related to war, poverty, gender discrimination, lack of opportunity, and so on. The failure to engage communities and understand cultural values and norms has sometimes worsened rather than relieved widespread community distress 4. The use of lay health workers helps to expand services and engender trust 5, but these workers typically make diagnoses and dispense medications or psychological therapies following a Western medical model. How could community engagement efforts align more closely with local culture? One basic strategy could be to start with local people on the ground. “Top-down” solutions (i.e., those developed by government experts) that are imposed on communities are often bureaucratic, reductionistic, overly prescriptive, and insensitive to local culture and context. The expensive and inefficient Veterans Administration Healthcare system in the U.S. is often cited as an example of the failure of top-down systems 6. By contrast, “ground-up” approaches (i.e., those developed by local stakeholders and communities) may better serve the goals of public mental health by valorizing local knowledge, competence, and resources. People on the ground – those experiencing behavioral health problems, their families, and their communities, aligned with local leaders, professionals, healers, and health workers – may in fact be in a better position to recognize local needs and resources, to understand local culture, to select and adapt appropriate evidence-based practices, and to innovate solutions. Local culture, however, may sometimes perpetuate stigma and even violations of human rights – hence the need for collaborations with professionals via mutual learning. Learning communities (multi-disciplinary groups focused on a specific health issue) have successfully combined local stakeholders with outside experts to discuss, select, and evaluate potential solutions 7. Community engagement could be enhanced on a global basis via several strategies. First, governments should give priority and funding to ground-up approaches. Community engagement in health care has a long and rich tradition, including principles and strategies for identifying and solving problems 8. Local community activation has in fact often produced positive changes and sometimes led to national and international health reforms: witness the women's health movement in the 1960s and the AIDS movement in the 1990s in the U.S.. Second, the field should recognize that people with behavioral health syndromes generally have goals that differ from those of professionals 9. Rather than more and more medications to reduce symptoms, people generally want support in finding meaningful functional roles. If local people (rather than industry, government, and the medical profession) were to choose services and goals, behavioral health would shift dramatically. For example, women who are oppressed and abused would be likely to emphasize education, advocacy, legal action, employment, and financial independence rather than poly-pharmacy. Third, healthcare systems should encourage people to develop natural resources, e.g., clubs, peer-support groups, spirituality, yoga, and other mindfulness-based therapies 10. These interventions, delivered by lay community members, are widely available in culturally specific forms and languages and can enhance prevention, resilience, treatment, and recovery. Government should encourage and strengthen these natural supports in local communities before assuming that more hospitals, professionals, and medications are the answer. Fourth, lay health care workers should be given the opportunity to collaborate with the people in their communities in selecting the medical and psychosocial interventions that they want and obtaining the training that they need to be effective 11. Likewise, they should be given the choice to veto or adapt interventions that are perceived as harmful or culturally insensitive. Such an approach may require extensive discussions within communities and suspension of Western hegemonic beliefs about the immutability of science-based interventions. Fifth, behavioral health technologies should be used to enhance all of these efforts in ways that maximize choice and cultural tailoring. A wide variety of web-based and mobile health applications are demonstrating effectiveness for prevention, empowerment, resilience, treatment, and maintenance 12. Low-income and middle-income countries are rapidly developing the connectivity that could facilitate widespread distribution, perhaps through lay health workers. Expanding and using these resources could helpfully overcome what is often perceived as the lack of a professional workforce while simultaneously empowering local communities. Global attention to positive behavioral health for all people is essential. We would not gainsay efforts to increase access to evidence-based interventions, but current efforts should include a meaningful understanding and respect for local cultures, communities, and resources.

BackgroundLicences to operate pharmacy premises are issued by statutory regulatory bodies. The Health Institutions and Facilities Act (Act 829) and Health Professions Regulatory Bodies Act (Act 857) regulate pharmacy premises and the business of supplying restricted medicines by retail, respectively, and this could create a potential regulatory overlap for pharmacy practice in Ghana. We theorise that the potential overlap of regulation duties stems from how law-makers framed issues and narratives during the formulation of these Acts.ObjectiveTo describe the policy actors involved, framing of narratives and decision-making processes relating to pharmacy premises licensing policy formulation.MethodsA qualitative study was conducted and data gathered through interviewing eight key informants and reviewing Hansards, reports, bills, memoranda and Acts 829 and 857. Data were analysed to map decision-making venues, processes, actors and narratives.ResultsThe Ministry of Health drafted the bills in July 2010 with the consensus of internal stakeholders. These were interrogated by the Parliament Select Committee on Health (with legislative power) during separate periods, and decisions made in Parliament to alter propositions of pharmacy premises regulations. Parliamentarians framed pharmacies as health facilities and reassigned their regulation from the Pharmacy Council to a new agency. The Pharmacy Council and the Pharmaceutical Society of Ghana could not participate in the decision-making processes in Parliament to oppose these alterations. The laws’ contents rested with parliamentarians as they made decisions in venues restricted to others. Legislative procedure limited participation, although non-legislative actors had some level of influence on the initial content.ConclusionImplementation of these laws would have implications for policy and practice and therefore understanding how the laws were framed and formulated is important for further reforms. We recommend additional research to investigate the impact of the implementation of these Acts on pharmacy practice and business in Ghana and the findings can serve as bargaining information for reforms.

In April 2020, Literacy Bridge Ghana (LBG) and Ghana Health Service launched a public health campaign in eight vulnerable districts in the Upper West Region. Community health nurses and volunteers are using an innovative digital technology, the Amplio Talking Book audio device, to share consistent and accurate information on COVID-19. So far, LBG has put three content deployments into the field. The urgency to disseminate information precluded a randomized control trial. But what we've learn from the project’s successes and failures will inform our next emergency response and future public health partnerships. For our poster, Amplio uses a journey map to track our challenges and short-term solutions, as well as long-term, technology-based solutions for future Talking Book programs. MORE DETAILS Through a partnership with Ghana Health Service (GHS), community health nurses (CHNs) and volunteers (CHVs) are using the Amplio Talking Book audio device to share consistent and accurate health messaging on COVID-19 in the Upper West Region. Launched in April, the COVID-19 awareness campaign is being implemented in 8 vulnerable districts near the Burkina Faso border. THE CHALLENGE Even in the best of times, Ghana’s under-resourced public health system struggles to provide basic health education and services. In the Upper West Region, remoteness, lack of infrastructure, low literacy, locally spoken languages, and limited access to mass media area barriers to reaching and sharing information with rural communities. The pandemic has put even more pressure on community health workers. OUR SOLUTION To address the crisis, Amplio and its affiliate, Literacy Bridge Ghana (LBG) leveraged existing relationships with Ghana Health Service (GHS), UNICEF Ghana, and local stakeholders to launch a rapid response using the Amplio Talking Book audio device to disseminate timely and accurate health information on COVID-19. Led by LBG, this is the main intervention reaching communities. The team built on the success of previous Talking Book programs in the region, including a Talking Book pilot conducted at 5 Community-based Health and Planning Services (CHPS) centers in 2019 and UNICEF Ghana’s Communications for Development program (2013-2019). With the rugged, easy-to-use Amplio Talking Book device, nurses and volunteers can share local language information across multiple topics. The device has a built-in speaker, so families and groups can listen and learn together. A built-in microphone allows listeners to record their feedback. Amplio’s technology makes it easy to update content and collect usage data in the field in areas there’s no electricity or internet. DEPLOYMENT MODEL Talking Books were distributed to 207 CHPS centers and 5 community health volunteers (CHVs) per district (40 total). Community health nurses (CHNs) use Talking Books to conduct group listening sessions during antenatal care visits and child welfare clinics. CHVs play Talking Book messages during household visits. The team also connected Talking Books to external loudspeakers to broadcast messages and ensure social distance and reach more people at lorry stations and in the markets. For this project, the content was produced by LBG in consultation with Ghana Health Service, using source material from government, WHO, and John Hopkins. Messages were recorded in 4 languages, enabling health workers to share accurate information in each community’s local language. The first content deployment (April-June) included expert interviews about coronavirus and government protocols, songs and dramas on symptoms, protection, and common myths, and endorsements from district health directors and religious and traditional leaders. In July, a second deployment addressed emerging community issues and concerns, including COVID-19 stigmatization, proper use of face masks, compliance with social distancing, and domestic violence and mental health issues. Deployment three included messaging on maternal and child health, livelihood development, and mental well-being. Usage data has shown that endorsement messages are among the most played, highlighting the importance of the project’s multi-stakeholder approach. A high rate of turnover among CHNs at the CHPS centers has highlighted a need for ongoing training and capacity building. LEARNING/IMPACT Amplio and LBG leveraged existing local stakeholder relationships in Northern Ghana and a uniquely suited digital technology for rapid response during a pandemic. Our poster shares some of the challenges and lessons learned from using Talking Books to help under-resourced, frontline health workers provide access to timely and culturally relevant health information during a frightening and evolving situation. FUTURE SOLUTIONS Amplio is launching a suite of online products and tools to help partners more easily launch and run their own Talking Book programs. An online learning portal with lessons and job aids will streamline training and build capacity for capacity for onboarding new staff. In addition, Amplio will soon release the Talking Book 2.0 that includes a rechargeable battery to reduce cost and waste. These enhancements will help Amplio’s partners more swiftly and effectively respond to future public health emergencies.