Self Determination Theory

Self-Determination Theory (SDT) is useful theoretical framework to understand individual’s motivational mechanisms to engage in positive health behaviours and health screening. SDT is a theory of intrinsic motivation [13] which has been applied to a number of different contexts including education [14], health behaviour change [15], and pro-environmental behaviour [16]. SDT assumes all individuals have the same three innate psychological needs, competence, relatedness and autonomy. The need for competence is deemed to be satisfied through successful completion of a goal or mastery of a skill alongside the ability to effect change [13]. The need for relatedness refers to a desire for acceptance from others and is deemed to be satisfied through the development of social connections and interpersonal relationships [13]. Finally, the need for autonomy is deemed satisfied when an individual feels able to make their own decisions without restriction or pressure from others. SDT research has demonstrated that these three motivational constructs are consistent across cultures [17–19].

Psychological theories such as SDT are useful to understand the intrinsic motivational mechanisms that underpin engagement and uptake of CVD (e.g. T2DM and hypertension) screening to in rural Northern Ghana. CBAM can identify the social environments and assets that may support or hinder motivation to engage. Recent research has sought to combine both SDT and CBAM [20] to strengthen the implementation and evaluation of community based interventions.

Ethics statement

Ethical approval was granted by the Navrongo Health Research Centre Institutional review board ref: NHRCIRB47I on 27/07/22. Prior to participation, informed consent was collected from all participants. Study staff provided translation services for those unable to read English, written consent was obtained where possible, with fingerprint consent taken from participants who could not sign.

Setting

This work was carried out in the Kasena-Nankana East Municipality and Kasena-Nankana West District in the Upper East Region of Northern Ghana. The two districts fall within the coverage area of the Navrongo Health and Demographic Surveillance System (HDSS) operated by the Navrongo Health Research centre (NHRC). The area has previously been found to be particularly underserved taking into account rurality and distribution of current health assets provided by the national health system [5].

Study design

We used a method of Community Based Asset Mapping (CBAM) based on the previously published Participatory Inquiry into Religious Health Assets, Networks and Agency (PIRHANA) model [21]. All CBAM approaches are participatory approaches [22] to development that are internally focussed on and help community members themselves identify capacity to problem solve with an emphasis on community resources rather than external resources. The approach is relationship driven and can build the social capacity of participating community members, establish and nurture ongoing relationships between community members [23]. The PIRHANA model was used to inform our approach as it has been specifically designed for use with faith communities and used extensively in SSA. Although the approach chosen was the most appropriate available, by nature, most models for asset mapping are highly context and condition specific [23] and further work will be required to develop and adapt screening models in order to optimise this approach in this setting.

Target participants and sampling

In October 2022, the research team at NHRC worked collaboratively with local churches and religious organisations, faith leaders and traditional and faith healers, healthcare professionals, public health officials and community members who seek health services within the communities in the Kassena-Nankana East Municipality and Kassena-Nankana West District in the Upper East Region, Ghana.

Purposive sampling [24] was carried out by the research team, in partnership with local faith and community leaders who identified participants based on their religion, membership of the relevant mosque or church congregation, age and gender to ensure that community members were suitably diverse in terms of gender, age, religion (Christianity, Muslim etc,) and socioeconomic status, and the views and insights were reflective of the target population who would have access to faith-based CVD risk screening services. Participants were identified and approached in person via community leaders who, together with the researchers, explained the purpose of the study and what their involvement would entail. Consented participants were provided with a mutually convenient appointment for a Focus Group Discussion (FGDs) or of in-depth-interview (IDIs).

FGDs, IDIs and workshops were convened at a central research facility and within church or mosque and health compounds with participants given non-financial-incentives (refreshments and hygiene products) or financial reimbursement for travel time and this was according to recommendations of the ethics committee.

Data collection

The research team hosted a series of workshops, focus group discussions and in-depth interviews which were inclusive and catered for individual needs including; language translation, running female only FGDs and holding groups in rural locations to address issues of access. FGDs and IDIs were based on an initial semi-structured topic guide which sought insights on the following: the context of religion and cardiovascular health in this community, the key factors which promote or harm health, identification of organisations surrounding churches which influence health in the locality, how the church/religious organisations can contribute to CVD/T2D treatment care and prevention and what next steps can be taken as a result of the data collected. Focus group discussions (FGDs)and in-depth-interviews (IDIs) were within church or mosque and health compounds. These settings were chosen due to their close proximity to the communities of interest, the spaces used were familiar to participants which aided more in-depth discussions. The choice was based on recommendations from local co-investigators who have experience and good ongoing relationships with local communities from previous research studies. Workshops were carried out at a central research facility attached to the local hospital. The majority of FGDs and IDIs were facilitated by three junior research staff (research assistants), who lived within local communities in Navrongo and were members of either the Christian or Catholic Church and are fluent in local languages (Kasem and Nankani). Workshops were facilitated by four members of the research team from Ghana and the UK who were experienced in qualitative research and all had a background in social sciences and public health. An iterative consultation and co-design process was used during the workshops, FGDs and IDIs. Researchers produced resources and graphics based on initial discussions which were refined following each discussion to produce final versions of the resources. All workshops, FGDs and IDIs were recorded and translated by bilingual research assistants and transcribed verbatim.

Data management and analysis

Data analysis was composite, whereby we conducted thematic analysis [25] of community members, Healthcare Professionals (HCPs) and policy maker’s insights relating to the mapping of health services provided in the locality. Geographical maps of local religious organisations and churches (>90) was compiled with contact details for faith leaders and wider organisational members. Graphical illustrations of community assets were co-developed with participants together with a list of recommendations of ‘wish list’ for the faith-based CVD screening programme, which is currently being developed as part of the wider study. Transcripts were coded by two researchers independently using NVivo 17. The thematic framework developed (S1 Fig) and an example of the coded interview transcripts (S1 Data) are provided as a supporting information files.

Salient themes and specific findings which informed the screening approach and design are described below. Key findings and all resources were shared with community members and faith leaders during a second round of interviews to promote accurate interpretation of data and confirmability of findings. Recommendations for screening were ranked and presented according to perceived importance from both a healthcare user (congregation member) and provider (HCP or faith leader) view.

Stakeholder recommendations on intervention

Focus group and workshop participants spoke about integration of the wider health service and involvement of staff as assets to leverage additional skill, legitimacy and trust including pharmacists, chemists, CHPS compound staff [27], hospital staff and staff from regional health facilities. Participants also discussed stakeholders involved in the publication of health messaging including local radio stations, local town opinion leaders or ‘chiefs’ and the role of social media in engaging younger generations. Owing to the security situation in the local area, participants identified local police and security services as assets which could improve trust and likelihood of attending large events if security can be assure

Thematic analysis of views expressed in both the FGDs and IDIs yielded a number of common themes, sub themes and recommendations (Table 2) necessary to facilitate a ‘successful’ screening programme characterised by high uptake and sustained engagement. These recommendations have been co-produced by congregation members, faith leaders and health professional and are presented in order of priority (Table 3).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Asset mapping responses.

https://doi.org/10.1371/journal.pgph.0002201.t002

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Stakeholder recommendations.

https://doi.org/10.1371/journal.pgph.0002201.t003

Participants prioritised operational factors including timing and location as key facilitators for success. In the rural location in which the study took place, a large proportion of the population are employed in the agricultural industry and it was felt that avoiding busy work periods during harvest (October-January) would make people more likely to attend mass screening. Members of the Muslim community felt that timings chosen would also need to respect prayer times during the day.

Congregation members were clear that confidentiality would need to be ensured during appointments as people are uneasy with disclosing disease status even within their own community. Steps would be needed to make sure that feedback and advice after screening would be on an individual basis to prioritise confidentiality.

Previous negative experiences of interactions with health services and screening events manifested in a level of mistrust in congregations. Participants felt that it would be important that the screening team were clear on their goals and open about motivations for providing screening. This ‘meeting of expectations’ from those undergoing screening, regards to number of tests available, how long a test would take, data security and availability of follow up support was vital to participants.

This ‘follow up support’ was seen as highly important in the context of a clear plan for maintenance of the programme and providing some form of service for people who screen positive or are identified as being at increased risk. Congregation members and faith leaders showed a need for clarity on who would fund medication which would be required and if there was an expectation for people to pay themselves. A small number of congregation members and faith leaders spoke about the viability of setting up welfare groups within their own organisation which would have responsibility for educating people on matters relating to health, as a low-cost way of supporting their congregation on an ongoing basis, utilising existing assets.

Implications of the findings

The findings of this study have important implications for both research and clinical practice within this context. The asset mapping combined with SDT provide a framework to understand motivations to engage and highlight opportunities to build in maintenance and sustainability, at low cost, utilising existing assets and skills which already exist within religious organisations, including medical knowledge and social welfare clubs. This could provide a means of overcoming one of the most significant challenges for implementation of embedding the screening within a health system with limited resource, particularly focussed on primary prevention, at low cost.

Strengths & weaknesses

This study utilised a novel approach to identifying assets and stakeholders involved in provision of health screening in a rural setting in SSA. By using a purposive sampling strategy [37], particularly sensitive to the differing levels of socioeconomic status, religion, gender education level, we have taken into account a wide variety of views to capture this diversity, essential in developing a screening method which takes account of individual barriers and strives to support those who are most vulnerable and suffer a disproportionate disease burden and has provided views through the dual lens of seekers and providers.

Despite the novelty of the methods used, there are limitations associated with focussing on the church. Though the church is an important institution and context in SSA, a proportion of the population may not engage and therefore may be missed via the method of recruitment we have chosen. The findings are likely to be very context specific and their generalisability to outside of Ghana is untested, even to more populous settings such as major cities; however, the work is important as deprived rural communities have lower access to healthcare generally, higher levels of poverty and delayed diagnosis of CVD and T2D [5]. There is a rich variety of religious expression, as evidenced by the diversity of participants and religious entities included here and by the underlying influence of African traditional beliefs and healing practices. There is no ‘one size fits all’ approach and public health interventions should take account of community assets and intrinsic motivations to engage before designing and delivering these interventions.