Improving experiences of neglected tropical diseases of the skin: Mixed methods formative research for development of a complex intervention in Atwima Mponua District, Ghana

Abstract

Integrated approaches to managing co-endemic neglected tropical diseases (NTDs) of the skin within primary healthcare services are complex and require tailoring to local contexts. We describe formative research in Atwima Mponua District in Ghana's Ashanti Region designed to inform the development of a sustainable intervention to improve access to skin NTD care. We employed a convergent, parallel, mixed-methods design, collecting data from February 2021 to February 2022. We quantitatively assessed service readiness using a standardised checklist and reviewed outpatient department registers and condition-specific case records in all government health facilities in the district. Alongside a review of policy documents, we conducted 49 interviews and 7 focus group discussions with purposively selected affected persons, caregivers, community members, health workers, and policy-makers to understand skin NTD care-seeking practices and the policy landscape. Outside the district hospital, skin NTD reporting rates in the surveyed facilities were low; supply chains for skin NTD diagnostics, consumables, and medicines had gaps; and health worker knowledge of skin NTDs was limited. Affected people described fragmented care, provided mostly by hospitals (often outside the district) or traditional healers, resulting in challenges obtaining timely diagnosis and treatment and high care-seeking costs. Affected people experienced stigma, although the extent to which stigma influenced care-seeking behaviour was unclear. National actors were more optimistic than district-level actors about local resource availability for skin NTD care and were sceptical of including traditional healers in interventions. Our findings indicate that improvement of the care cascade for affected individuals to reduce the clinical, economic, and psychosocial impact of skin NTDs is likely to require a complementary set of interventions. These findings have informed the design of a strategy to support high-quality, integrated, decentralised care for skin NTDs in Atwima Mponua, which will be assessed through a multidisciplinary evaluation.

Fig 1. Map of Atwima Mponua District showing the location of GHS facilities by type.

Background shading reflects population density (in black) alongside tree (green) and crop (pink) cover based on satellite imagery. The inset map shows the location of Atwima Mponua in Ghana. Basemap was generated in qGIS using district boundary files provided by GADM (https://gadm.org/) and landcover and population data provided by ESA WorldCover project (modified Copernicus Sentinel data (2021) processed by ESA WorldCover consortium: https://worldcover2021.esa.int/download) and GRID3 (Ghana Settlement Extents v2.0: https://data.grid3.org/datasets/GRID3::grid3-gha-settlement-extents-v2-0/explore). These data sources are all provided free of charge, without restriction of use (CC BY 4.0). For information on licensing: https://gadm.org/license.html, https://worldcover2021.esa.int/download, https://data.grid3.org/datasets/GRID3::grid3-gha-settlement-extents-v2-0/about.

Fig 2. Timeline of data collection activities.

Fig 3. Care-seeking pathways of five people confirmed (red outlines) or presumed (yellow outlines) to have BU.

Signs and symptoms which prompted care-seeking and informed diagnostic decision-making are shown in yellow boxes. Care and advice were provided by a range of people including friends and family (orange boxes), primary health centres (light blue), hospitals (dark blue), herbalists (dark green), and faith healers (light green). No CHPS compounds were consulted. Facilities listed in diagram include places people consulted both within (Gyereso, Nyinahin) and outside (Asuofia, Bibiani, Kumasi/KCCR, Nkawie, Toase) Atwima Mponua District. One herbalist was located outside district (Nkroma). In two case studies (C and E), people presumed to have BU had not been tested in a lab by the time of interview. HF: Health facility.