Introduction

The World Health Organization (WHO) Neglected Tropical Diseases (NTD) Road Map for 2021–2030 [1, 2] set global targets for the control, elimination, and eradication of 20 diseases. Traditionally, NTD programmes have been predominantly vertical, but the new strategy advocates integration of activities across NTDs and incorporation within the general health system. NTDs involving the skin (skin NTDs) have received less funding and attention than NTDs managed primarily through mass drug administration, and consequently intervention activities have often been sporadic, donor driven, and limited in scope [3]. Integration has emerged as an approach with potential to strengthen activities focused on skin NTDs because of the essential need for complex clinical assessment in diagnosis; their relatively low prevalence and focal nature; and a requirement for prolonged care for the primary infection and associated complications.

Ghana reports the highest number of yaws cases in Africa [4] and the second-highest for Buruli ulcer (BU) [5]. Leprosy is less common (200–300 cases are diagnosed annually), while scabies, lymphatic filariasis, and cutaneous leishmaniasis are endemic. BU and yaws commonly affect children and are predominant in central and southern Ghana, whilst leprosy is reported nationwide. These diseases have a substantial impact on quality of life, resulting in disability, stigma and sometimes mental distress [6], for affected individuals and family members [7–10].

In 2021, Ghana developed an NTD Masterplan, which focused on integrated approaches and multisectoral collaboration [11] but implementation requires collaborative intervention development, adapted to local contexts. Our formative research in Atwima Mponua identified factors shaping care-seeking, diagnosis, and management of skin NTDs and other skin conditions [12]. We found limited community awareness of skin NTDs signs and symptoms, complex moral associations, an absence of well-trained staff, a complex and fragmented healthcare landscape, and the economic burden of care-seeking exacerbated the burden of these diseases. School children in the district with skin NTDs also face substantial social exclusion by peers and staff. While studies have demonstrated that case-finding activities can be integrated across skin NTDs [13–15], there is little evidence on how best to integrate health system responses more broadly to build sustainable holistic models of skin care [16, 17].

Here, we describe the development of an integrated and decentralised skin health strategy to improve experiences of skin NTDs in Atwima Mponua district in Ghana. We outline the processes through which a theory of change, (ToC), informed by formative work, was developed and describe plans for implementation within existing health system structures. The intervention will be evaluated using a before-and-after design. While designed to respond to the specific context of the study district, this work is also intended to produce generalisable findings regarding the implementation of global and national policies promoting integrated approaches for skin NTDs.

Methods

Finalising intervention components

Once key intervention areas had been established, working groups were tasked with developing detailed intervention designs. The community intervention group included social scientists; the supply chain and information systems intervention group included health economists and project managers; and the decentralised service delivery and health worker training groups included clinicians, epidemiologists and social scientists. Over approximately three months, groups met online and by email to describe intervention designs detailing activities involved, material inputs, key stakeholders, and expected outcomes. They articulated assumptions concerning how the intervention would lead to impact, major risks, and potential unintended consequences. Guided by an intervention reporting checklist (S1 Checklist) [20], they described how interventions would be delivered, identified individuals responsible for delivery and supervision, and outlined provisional timelines and budget implications. Finally, they drafted a framework for monitoring and evaluation. Intervention summaries from each group were compiled into a single ToC (Fig 1).

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Fig 1. Theory of change for the integrated skin health strategy in Atwima Mponua district.

https://doi.org/10.1371/journal.pgph.0002809.g001

In November 2022, a two-day intervention finalisation workshop was held to discuss the practicality of operationalising intervention activities and further refine implementation plans. Attendees included the deputy director for public health, representatives from the district health management team, healthcare workers from every health facility across the study district, and members of the study team.

Results

In co-development workshops, stakeholders agreed the strategy should aim to improve wellbeing for people with skin NTDs by reducing their negative physical, psychosocial, and economic impact. Participants determined the strategy would need to comprehensively address skin conditions and wounds, rather than skin NTDs in isolation. Despite some concerns that health services could be overwhelmed by the number of individuals with common skin conditions, stakeholders believed that a wider focus on skin health would be more acceptable to people, encourage prompt care-seeking, and might prove an efficient approach to improving health and strengthening health service provision. Participants prioritised developing a strategy that was not reliant on external funding and would in principle be practicable for the district health management team to implement in the study district and, if successful, beyond.

Health system stakeholders ranked improving community awareness of skin lesions and services and training staff as the activities likely to have the highest impact, whilst researchers ranked decentralisation of care and improving community awareness of skin conditions and services as highest impact (Fig 2). Both groups of stakeholders identified community awareness and staff training as most feasible to deliver.

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Fig 2. Prioritisation exercise results.

Participants ranked 12 intervention options across three domains: feasibility, affordability, and potential impact. Options were scored based on their ranking within each domain. Twelve points were assigned for every top ranking, eleven for each second ranking and so on, with one point assigned for the lowest ranking option. Mean scores for each option were calculated for researchers (vertical axis) and health system stakeholders (horizontal) separately. The total number of participants ranking each option highest was calculated and listed in the legend sequentially for feasibility, affordability, and impact. Numbers in brackets show the number of people voting this option highest for (feasibility) (affordability) (impact) of 45 participants (27 researchers and 18 stakeholders), A = Community awareness on skin problems and services through videos and posters to promote care seeking (20) (4) (10), B = Community awareness on skin problems and services through patient testimonials to promote care seeking (2) (3) (3), C = Building a community-of-practice linking traditional healers, volunteers and drug sellers with health facilities and district staff, focused on referral (0) (1) (0), D = Training for health staff on skin diseases, sample collection and management of skin problems (3) (0) (9), E = Training for health staff on respectful care (0) (1) (1), F = Developing a supervisory system for performance monitoring and to support local innovations in health centres and CHPS (2) (3) (0), G = Providing funds to support transport of samples (2) (1) (0), H = Using KCCR as a hub for supplying sample collection consumables (4) (9) (0), I = Decentralising care for skin conditions and skin NTDs to health centres and CHPS (0) (0) (9), J = Dispense drugs to the health centre / CHPS rather than patients collecting from a district/referral hospital (1) (5) (1), K = Availability of a wound care kit at health centres / CHPS free to patients (1) (0) (1), L = Package to support self and family care in the community (0) (8) (1).

https://doi.org/10.1371/journal.pgph.0002809.g002

The strategy therefore focuses on an intervention to decentralise care for skin conditions, while including interventions to support a self-care delivery pathway, community engagement, and referral (Fig 1). The following sections describe each of these interventions in turn.

Some interventions were considered but excluded from our final strategy. For example, formal involvement of traditional healers and those selling allopathic medicines (e.g. drug sellers) within the referral system was considered a potential mechanism to improve linkage to care; however, concerns that such a role might be viewed as official endorsement of informal actors with potential negative consequences meant this component was not pursued.

Discussion

We developed an integrated skin health strategy adapted to the context of Atwima Mponua district using a multi-stage, iterative, consultative process. The strategy aims to improve wellbeing for people with skin NTDs via a focus on decentralisation of diagnosis and treatment of skin conditions to peripheral health facilities, with components to support self-care and community engagement and referral. Our intervention is aligned closely with the GHS NTD Masterplan [11] and the WHO Roadmap [1, 2]. Delivering the intervention primarily through existing health system structures has the potential to ensure long-term sustainability.

Our strategy differs in important ways from the approach we anticipated prior to conducting formative research. Our original focus on “severe, stigmatising skin diseases,” as designated by our project’s funding, shifted to “skin NTDs” in line with the evolving policy context and to avoid stigmatisation. Reflective practice and engagement with stakeholders broadened our scope further from skin NTDs to skin health as concerns were raised about the effectiveness and cost-effectiveness of a strategy that would not include treatment for most people with skin problems. We originally conceived an “integrated case finding and management” strategy [30], but our formative research revealed limited access to timely, high-quality, affordable care–rather than “finding” cases–was the significant limiting factor to improving outcomes, leading to our focus on decentralised care. We originally envisaged supporting a broad community of practice including traditional healers, as had been done successfully in other countries [31]; however, stakeholders did not support this approach in Ghana. Our findings thus demonstrate the importance of formative research and iterative engagement with a broad range of stakeholders in co-creating an acceptable implementation plan for an “integrated skin NTD strategy”.

Our developed strategy builds on the existing literature in important ways. Several studies have attempted to address barriers to care for one or more skin NTDs both in Ghana and in other contexts [32–35]. Active case-finding activities have previously been shown to identify more cases than would otherwise present to the health service [34, 36], but these approaches neither tackle fundamental barriers to care-seeking, nor result in widespread improvements in the care available, and have required substantial financial support and delivery by a dedicated research or implementation team. There is evidence to suggest decentralised care models for BU appear to be both effective and sustainable [33]. Decentralisation aligns with the Ghana NTD Masterplan [11], the NTD roadmap agenda for incorporating NTD care into general services, and Universal Health Coverage strategies [1].

While some aspects of our intervention strategy may be specific to Atwima Mponua, other aspects and the methods we used may be more generalisable. An integrated NTD strategy is necessarily a complex intervention [37], not just because the individual diseases are clinically complex [1], but because of the nature of the interventions, their interdependence, and their interactions with context. We describe in this article (and in a report of our formative research) the steps we employed to understand the local context and engage meaningfully with stakeholders to develop this strategy using an explicit ToC. The activities within our strategy may need to be adapted for other districts in Ghana or in other countries, with the degree of adaptation dependent on the similarity of the target context to Atwima Mponua [38, 39]. Nonetheless, we would expect the mechanisms of action through which activities are expected to lead to overall impact could be more widely relevant [38, 39]. In particular, the problem of limited access to care for skin NTDs is widespread, which creates potential for our strategy, if shown to be effective and cost-effective, to be transferable. To enhance transferability, our proposed strategy will be delivered almost exclusively by the GHS predominantly using existing structures.

Our intervention development approach has strengths and limitations. Firstly, we used the TIDieR checklist to ensure all intervention elements have been defined. Secondly, it was informed by a large body of formative research [12]. We identified factors shaping wellbeing for people with skin NTDs and examined evidence of what strategies had been successful. Thirdly, the intervention was developed over a series of events and ongoing engagement with a range of stakeholders, allowing iterative refinement of its scope and focus. One limitation is that our formative work focused predominantly on NTDs, but our intervention will have a broader scope. It is plausible we missed important insights into wider issues of skin care, which may limit the effectiveness and cost-effectiveness of our strategy. Although we held multiple meetings, not all stakeholder groups were represented at every workshop, and it is possible our final intervention does not fully capture the concerns of all relevant groups. Finally, we opted not to include some potential components such as direct involvement of traditional healers. Future studies addressing the added value of these components would be valuable.

The strategy we developed has several implications for NTD programmes and research. WHO advocates for mainstreaming of activities within the health service and integration of interventions across NTDs; however, we have shown that addressing the burden of skin NTDs also requires integration across the care pathway and strengthening of wider health system functions. This requires considering the capacities and social dynamics of primary healthcare facilities to engage with skin NTD care, alongside other spaces at the margins of the health system such as schools, pharmacies and sites of traditional and religious healing [27, 40]. It is important for policymakers, programme managers, and academics to recognise control of skin NTDs requires complex interventions in complex systems [37, 41–43]. While vertical MDA programmes may successfully tackle some NTDs, replicating this approach–for example, with strategies focused only on case detection integrated across diseases–will not address the key problems facing people with skin NTDs in many contexts. Alongside the intervention implementation, we will conduct a rigorous, multidisciplinary evaluation to assess the effectiveness, costs, and cost-effectiveness of our strategy and the processes by which the planned activities contribute–or not–to intended and unintended outcomes.

Supporting information

Acknowledgments

We wish to thank the individuals and communities for their participation in the work of the Skin Health Africa Research Programme. We sincerely acknowledge staff of the Atwima Mponua District Health Directorate. We wish to thank the policy makers within the Ghana Health Service who dedicated their time to participate in the development of this intervention.

Membership of SHARP collaboration

Endalamaw Gadisa (Armauer Hansen Research Institute, Ethiopia), Mirgissa Kaba (Addis Ababa University, Olivia Dornu (Kumasi Centre for Collaborative Research), Saba Lambert, Sinead Langan (London School of Hygiene and Tropical Medicine, UK)