## 3 Results
### Ghana  
#### 3.3.1 Quality Improvement Project Keta Municipal Hospital (KMH)  
A total of 757 prescriptions were assessed during the 39 weeks of the Quality Improvement project. Compliance with the antibiotic policy showed improvement from 18% to 70% within 3 months but then reduced to 57%, which was sustained until June 2020 (Figure 1). The aim of the project to achieve 70% compliance with the policy was met initially but not sustained. Improved compliance with the policy was not sustained due to a prescriber changeover just before the COVID-19 pandemic of approximately 60%. Planning for the COVID-19 response reduced the time available for the training of new staff. However, it was encouraging to see that compliance with the policy did not return to baseline at this time. Successful interventions were giving monthly feedback to prescribers both individually and in a meeting format and improving prescribers' access to guideline through the display of antibiotic policy as posters on the wall in all working areas.  
3.2 Local Pharmacists Lead on Implementing the CwPAMS Antimicrobial Guidelines App at Korle-Bu Teaching Hospital (KBTH)  
Fifty-five KBTH colleagues' contact details were collected after they were recruited to download and use the app by twelve KBTH superuser pharmacists: 32 doctors, 16 pharmacists and 7 nurses. Of the 55 colleagues eligible to complete the survey, 16 were excluded due to incomplete contact details (five doctors, as they did not provide an email address, and 11 colleagues (10 doctors and one nurse) provided incomplete email addresses. Of the remaining 39 colleagues, less than half 17/39 (45%) responded to the survey. The majority (16) were pharmacists and one microbiologist: 16 heard about the app during the June 2019 visit, 11 used the app once a week and 4 had not used the app at all since downloading it. Thirteen stated that they found the app easy to navigate, and 14 reported that it was easy to recommend to colleagues.  
Data from the app showed that the highest number of hits on the CwPAMS app Ghana page was in October 2019 (827), followed by July 2019 (569) and then November (438) 2019 (Figure 2). Hits by doctors were the highest in October 2019 (158), followed by February 2020 (72) and then November 2019 (50).  
Figure 1: Percentage compliance with antimicrobial guidelines in outpatient prescriptions for pneumonia in Keta Municipal Hospital, Ghana.  
There was a low response rate to the survey to assess the effectiveness of the app from medical colleagues.  
Issues with using the app were identified as technical issues with the app and lack of data/Wi-Fi. Although 16 respondents stated that they would recommend the app to colleagues, only three (17%) recommended the app to more than six people. The data for the app represented all hits on the CwPAMS app Ghana page, and Table 2 shows that other Ghana partnerships also promoted the app. The CwPAMS rollout of the app in Korle-Bu was in June 2019 and corresponded to the increase seen in July of people accessing the app. The education and promotion of the app in the other partnership hospitals during October corresponded to the October peak in use of the app (Figure 2). Lower levels of engagement with the app were seen starting in March 2020. This may be due to the pandemic and the fact that COVID19 guidance was not included, or it could have been due to prescribers already having the app.