TYPE Original Research PUBLISHED 31 July 2023 DOI 10.3389/fpubh.2023.1133151 Pilot implementation of OPEN ACCESS community health advocacy EDITED BY Manuela Berto Pucca, teams to improve the Sáo Paulo State Universty, Brazil REVIEWED BY eectiveness of long-lasting Altair Seabra de Farias, University of the State of Amazonas, Brazil Praveen K. Bharti, insecticide net distribution National Institute of Malaria Research (ICMR), India through both campaigns and *CORRESPONDENCE Franklin N. Glozah fglozah@ug.edu.gh continuous channels in Ghana: a RECEIVED 28 December 2022 ACCEPTED 07 July 2023 qualitative study of opportunities PUBLISHED 31 July 2023 CITATION Dako-Gyeke P, Hornuvo R, Glozah FN, and barriers to implementation Asampong E, Tabong PT-N, Nwameme A, Chandi GM, Peprah NY, Gittelman D and Adongo PB (2023) Pilot implementation of Phyllis Dako-Gyeke1, Ruby Hornuvo1, Franklin N. Glozah1*, community health advocacy teams to improve the eectiveness of long-lasting insecticide net Emmanuel Asampong1, Philip Teg-Nefaah Tabong1, distribution through both campaigns and 1 2 3 continuous channels in Ghana: a qualitative Adanna Nwameme , Gloria. M. Chandi , Nana Yaw Peprah , study of opportunities and barriers to David Gittelman4 and Philip B. Adongo1 implementation. Front. Public Health 11:1133151. 1Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra, doi: 10.3389/fpubh.2023.1133151 Ghana, 2Ghana Health Service, Ga North Municipal Health Directorate, Accra, Ghana, 3National Malaria COPYRIGHT Elimination Programme, Accra, Ghana, 4Health Campaign Eectiveness Coalition, Task Force for Global © 2023 Dako-Gyeke, Hornuvo, Glozah, Health, Decatur, GA, United States Asampong, Tabong, Nwameme, Chandi, Peprah, Gittelman and Adongo. This is an open-access article distributed under the terms Introduction: In Ghana, the National Malaria Elimination Programme (NMEP) of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction distributes long-lasting insecticide net (LLIN) to households for free through the in other forums is permitted, provided the periodic point mass distribution (PMD) campaign and continuous distribution to original author(s) and the copyright owner(s) populations most vulnerable to malaria. It is known that the existence of eective are credited and that the original publication in this journal is cited, in accordance with and functional community-based groups could influence positive behaviours accepted academic practice. No use, regarding health interventions promoted through health campaigns. However, distribution or reproduction is permitted which there is no evidence of functional community-based groups that aim to improve does not comply with these terms. the eectiveness of LLIN distribution campaigns by transitioning into primary healthcare delivery. This study aimed to explore the opportunities and barriers to the pilot implementation of co-created community health advocacy teams (CHATs) to improve the eectiveness of LLIN distribution through both campaigns and continuous channels in Ghana. Methods: A qualitative research approach was used among 43 CHAT members across six communities in the Eastern and Volta regions of Ghana. The CHAT constitutes significant community actors whose roles are centred on key elements of community/social mobilisation and capacity building, all nested in social and behaviour change communication (SBCC) strategies. The CHATs were pilot implemented in all study communities for 4 months after which we identified opportunities and barriers during implementation. CHAT members participated in six focus group discussions which were audio recorded, transcribed verbatim, and analysed thematically using the NVivo 13. Results: CHATs were instrumental in sensitising community members through SBCC strategies. Moreover, there were changes in the behaviour of community Frontiers in PublicHealth 01 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 members who were receptive towards and participated in CHAT activities. Community members were accurately informed about malaria (e.g., causes and preventive measures). However, the CHAT experienced barriers during implementation, including a lack of financial support to aid in transportation, organisation of meetings, and outreach activities. Additionally, the level of participation by CHAT members in activities and the medium of communication among members were key areas of concern. Conclusion: TheCHATswould be instrumental in promoting LLINs’ use during and after PMD campaigns through community outreaches. It is therefore necessary to provide resources to support their operations and a good network to address communication barriers. Finally, continuous capacity strengthening of CHAT members by the NMCP is important. KEYWORDS community health advocacy team, implementation research, intervention, long-lasting insecticide net, malaria, Ghana 1. Introduction The National Malaria Elimination Programme (NMEP) in Ghana is responsible for mass LLIN distribution campaigns Malaria is a public health concern with nearly half of the world’s by engaging and involving stakeholders at all levels (national, population at risk of infection, and the major cause of morbidity regional, district, sub-district, and community) (3). In accordance and mortality in many resources constrained settings especially for with Ghana’s Malaria Strategic Plan (2021–2025), the mass LLIN children under 5 years (1). TheWorld Health Organisation (WHO) distribution campaign seeks to protect at least 80% of the has recommended long-lasting insecticide-treated nets (LLINs) as population at risk with effective malaria prevention interventions a core intervention in all malaria-endemic settings. The LLIN through household registration (90%) and distribution (90%) in is estimated to reduce malaria cases by 50% (2). To reduce the target regions (4). Over the years, the NMCP together with global burden of malaria by 90% by 2030, WHO advises universal its partners continues to scale up the LLIN ownership through coverage with effective vector control utilising LLINs and indoor point mass distribution (PMD). As part of efforts to achieve residual spraying (IRS) for all persons in malaria-endemic areas (1). universal coverage of LLINs, continuous distribution of LLINs to Malaria is a parasitic and infectious disease caused by the population most vulnerable to malaria (i.e., pregnant women, Plasmodium. The parasite is transmitted through the bite of an mothers of children under 5 years, and primary school children) infective female Anopheles mosquito during a blood meal from is done through antenatal care clinics (ANC), child welfare clinics one person carrying the parasite to the other. The main vectors (CWC), and schools. From 2010 to 2012, there was a nationwide of malaria in the country are Anopheles gambiae complex and LLIN door-to-door mass distribution and the hang-up campaign, Anopheles funestus group. In Ghana, malaria is mainly caused which was followed by another mass distribution campaign in by the Plasmodium falciparum parasite, which is responsible for 2018. Despite progress in overall LLIN ownership, the challenge >85% of malaria cases. The other malaria parasites are Plasmodium remains to reach the NMCP strategic plan target of 80% usage malariae and Plasmodium ovale. Because the malaria parasite is among pregnant women and children under 5 years. Moreover, the found in the red blood cells of an infected person, malaria can also 2019 Ghana Malaria Indicator Survey shows that 67% of Ghanaian be transmitted through blood transfusion, organ transplant, or the households have access (percentage of the population that could shared use of needles or syringes contaminated with blood. Malaria sleep under an LLIN if each LLIN in the household were used by may also be transmitted from a mother to her unborn infant before up to two people) to LLINs, but only 43% of Ghanaian household or during delivery (“congenital” malaria).Malaria is hyper-endemic population slept under a net the night before the survey (3). This in Ghana with transmission occurring year-round, and the peak indicates that a relatively large number of people have not used the transmission occurring between June and October (rainy season). LLIN despite the distribution campaign. Although these campaigns The Ministry of Health (MoH) in Ghana oversees healthcare have exposed a large proportion of Ghanaians to LLINs, they may organisations in Ghana and this includes public, private, or not have led to desired health-related behaviours (i.e., sleeping in traditional ownership in the country. The Ghana Health Service LLINs every day). (under the MoH) is a public service body that provides and Various studies have documented barriers to LLIN use, supervises public healthcare in the country. It has eight directorates which include inadequate distribution of nets per household, that include the National Malaria Elimination Programme, limited social and behaviour change communication (SBCC) regional and district health administration, and subdistrict health activities to support distribution, lack of malaria education administration, which includes Health Centres and Community- on the proper use of LLINs, and complaints of nets being based Health Planning and Services (CHPS). distributed to communities with little or no information on their Frontiers in PublicHealth 02 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 relevance for malaria prevention (5–7). Furthermore, LLINs are 2. Materials and methods not used following complaints of burning sensation or itching from sleeping under the net and inconvenience due to heat. 2.1. Study design At the community level, LLINs are sometimes inappropriately used for gardening/fencing, fishing, crop farming, and processing This study used a qualitative research approach to explore the of farm produce (6, 7). The inability to hang LLINs due opportunities and barriers experienced by CHAT members in a to housing type and sleeping places has been observed in pilot implementation of the intervention. A total of six districts other communities. Barriers that health workers experience (one community per district) across two regions in southern Ghana include a lack of community mobilisation training, inadequate participated in this study. These were communities in districts personnel, lack of follow-up, involvement, and supervision where the 2021 PMD campaigns of LLINs were ongoing. These (8, 9). communities were selected to avoid possible biases concerning To achieve national LLIN access and use targets, innovative community engagement (i.e., communities that are yet to be social interventions that facilitate behaviour change may be involved in registration and distribution activities for the 2021 needed both during and in follow-up to campaigns (10). Social PMD campaign) by ensuring that components align with the innovation is described as a collaborative approach that generates timelines of the National Malaria Elimination Programme (NMEP) ideas to improve community or hospital delivery systems (11). and the funder. The study was also conducted in districts with Social purpose emphasises engaging concerned communities the highest malaria prevalence as reported in the District Health within which innovative approaches fulfilling both social and Information System: Ho West (Tsito-−90%), Ho (Takla Hokpeta- health concerns will be distributed (11). Such community-based −75%), and Agortime Ziope (Kpetoe-−100%) in the Volta Region; programmes allow the government, health agencies, social actors, and Birim South (Apoli-−94%), Achiase (Achiase-−94%), and and individuals to work closely with populations impacted by AbuakwaNorth (Kukurantumi-−93%) in the Eastern Region (Data diseases, especially infectious conditions. The Community-based source: DHIMS 2). At the time of the study, continuous/routine Health Planning and Services (CHPS) in Ghana is a national-level LLIN distributions in schools and antenatal care clinics were programme that aims to provide accessible, equitable, efficient, and ongoing in these communities. high-quality healthcare (12). The CHPS programme is considered a pragmatic strategy for achieving universal health coverage of a basic package of essential primary health services. The CHPS 2.2. Population and sample concept involves the provision of door-to-door primary healthcare services to community members by trained nurses known as The study population comprised adult men and women from community health officers (CHOs) and has proven to be successful communities within the selected districts across two regions in in providing maternal, reproductive, and child health services in southern Ghana (Eastern and Volta Region). The sample consisted communities where they are much needed (12–14). CHOs provide of 43 members (18 women and 25 men) of the CHAT from six antenatal care, family planning, health education, outreach clinics communities in the two regions (Figure 1). for delivery of child welfare services, and school health services. Some community health workers (e.g., health volunteers and community health nurses) are involved in household registration 2.2.1. The community health advocacy team and distribution of LLINs during the PMD campaigns, after which The community health advocacy team (CHAT) was co- they are remunerated for their work. These community health created through the participatory learning in action technique workers may not necessarily be the ones mandated to engage in using participatory workshops (PWs) which is a practical LLIN promotion and use both during and after campaigns. approach. This approach involves adaptive research strategies that In order to use a person-centred approach to promote LLIN enabled diverse groups and individuals to learn, work, and act use which leverages CHPS and ensures community involvement, together in a co-operative manner, to focus on issues of joint ownership, and sustainability of the LLIN mass distribution concern, identify challenges, and generate positive responses in campaigns, a community health advocacy team (CHAT) was co- a collaborative and democratic manner. This was done by using created in six Ghanaian communities (15). The terms of reference the findings from the initial phases of the project (i.e., desk of the CHAT are generally based on NMCP’s key elements of review, focus group discussions (FGDs), key informant interviews the campaign at the sub-district level (e.g., household registration, (KIIs), and baseline surveys) (15). The participatory workshops training, SBCC, and logistics). Specifically, the CHAT members involved various stakeholders (i.e., project investigators, NGO should be equipped with skills in community mapping; promoting representatives, school health education programme coordinators, correct LLIN use, maintenance, and repurposing; leadership and ANC nurses, disease control officers, district health management supervision, record-keeping, and interpersonal and persuasive teams (DHMTs), CHOs, community leaders, and opinion leaders). communication. This study explores the opportunities and barriers Findings from the PWs suggested the establishment of a CHAT can to the pilot implementation of co-created CHAT in Ghana. The be instrumental in facilitating and improving the effectiveness of goal is to transition the community-level LLIN ownership and LLIN distribution campaigns within communities in Ghana. use promotional functions provided during the PMD Campaigns A CHAT consists of nine members who are influential in with ongoing LLIN promotion post-campaigns for continuous their communities: health officers, religious leaders, school distribution under the Community Health Planning and Services health education programme coordinators, assemblymen/women, (CHPS) programme. community information officers, representatives from any of Frontiers in PublicHealth 03 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 FIGURE 1 Location of the six districts in the Eastern and Volta Regions of Ghana. the security services, community-based organisations, and to community members for the first time) at an organised traditional authorities. community durbar (an outdoor community gathering, where The CHAT members were trained by officials from the members of the community are present to discuss issues of NMCP and project investigators as part of their capacity- community importance). These community durbars included strengthening efforts. They were trained in key elements of the traditional leaders, community members, religious leaders, opinion NMCP’s campaign (i.e., training, registration, SBCC, logistics, leaders, representatives from the Ghana Health Service (Regional distribution, and supervision) and skill-enhancing strategies in Deputy Director of Public Health (DDPH), District Director(s), leadership, communication, and community mapping, as well regional and district malaria focal persons, CHATmembers, project as record-keeping competencies. This training provided CHAT investigators, and representatives from the NMCP) in the six members with the capacity to carry out malaria education and study sites. prevention activities as well as the promotion of net use within communities and primary healthcare levels during and after LLIN campaigns. Specifically, CHAT members are expected 2.2.2. Long-lasting insecticidal net to support PMD for LLIN campaigns at the community level, The NMEP is responsible for reducing malaria morbidity as well as provide support on the continuous distribution of and mortality in Ghana and has, over the years, carried out LLINs through the school-based, antenatal, and child welfare several malaria prevention interventions such as PMD of LLINs clinics at the community level, development of context- (Figure 2). The distribution and the use of LLINs are core based social and behavioural change communication (SBCC) interventions for preventing malaria infection in malaria-endemic strategies on malaria prevention and regular use of LLINs, countries, including Ghana. LLINs provide protection against sensitise the community on the proper use of LLINs and its mosquito bites, repel, and kill mosquitoes, thereby reducing the maintenance, support with the management of LLINs logistics transmission of malaria parasites and decreasing malaria risk and accountability, and support other community-based health at the individual and community levels when high coverage campaigns. All stakeholders agreed that the CHAT would meet is achieved (Figures 3, 4). Mosquito nets can be obtained quarterly to discuss implementation progress and re-strategizing mainly during PMD campaigns; however, as part of targeted as needed. continuous distribution programmes, LLINs are distributed After successful training of the CHAT, a total of six through antenatal care (ANC), child welfare clinics (CWC), and community health advocacy teams, one in each of the six districts, primary schools. LLIN can be used for up to 3 years or after were inaugurated and out-doored (an introduction of CHAT 20 washes. Frontiers in PublicHealth 04 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 FIGURE 2 School children receiving treated mosquito net in Ghana. Source: Malaria consortium. FIGURE 3 Mother and child sleeping under treated mosquito net. Source: WHO Africa. 2.3. Data collection health and with several years of conducting qualitative research and interviews. Saturation was achieved during interviewing A total of six focus group discussions (FGDs) were organised to as similar themes emerged repeatedly in the course of the explore the opportunities and barriers of the CHAT intervention interviews. Informed consent was sought from all participants after four months of pilot implementation in all six study and FGDs were audio-recorded. Each FGD lasted approximately communities. Each FGD included members of the CHAT, with one hour. a total of 43 participants in all six FGDs. Some CHAT members were playing key roles at a traditional function during the time of data collection and hence could not participate. All 2.4. Data analysis participants were contacted with the assistance of the conveners of the team and an arrangement was made for the FGDs to All audio-recorded FGDs were transcribed verbatim and be conducted. The FGDs were conducted by trained qualitative augmented with researchers’ field notes made through observations research assistants using a designed implementation stage FGD and during FGDs. A codebook was developed based on guide within a relaxed and convenient atmosphere while observing the research objectives. The codebook development involved all COVID-19 protocols. The interviews were conducted by qualitative experts from the project team who reviewed the various experienced research assistants who have been trained in public components of the codes to ensure they aligned with the datasets. Frontiers in PublicHealth 05 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 FIGURE 4 Demonstration of LLIN use, care, and maintenance. Source: Ghana Health Service. The data resulting from transcriptions were evaluated, coded, 3. Results and analysed using the thematic analysis method, employing both deductive and inductive processes as described by Braun The findings of the study are presented under the following and Clarke (16). The data were analysed thematically and headings: sociodemographic characteristics of participants, managed using the NVivo software version 13. The initially CHAT implementation opportunities [increase LLIN use and developed codebook was revised throughout the coding process malaria prevention (malaria control interventions) through CHAT to include emerging codes. The consolidated criteria for reporting educational and SBCC activities, community participation in qualitative studies (COREQ): 32-item checklist was used to guide CHAT activities], and CHAT implementation barriers. the process. 3.1. Sociodemographic characteristics of 2.5. Ethical consideration participants Ethical clearance was obtained from the Ghana Health Service A total of 43 participants comprising 18 women and 25 Ethics Review Committee (GHS-ERC: 002/06/21) before the men, aged between 23 and 73 years, were involved in the focus commencement of all data collection. All research assistants group discussions. Participants were the CHAT members from the received specific training before data collection as per the study’s selected districts in the Eastern Region (Kukurantumi, Achiase, training protocol. and Apoli) and Volta Region (HoKpeta, Tsito, and Kpetoe) of Before beginning, all study participants provided written Ghana. Table 1 presents the socio-economic characteristics of the informed consent after reviewing the study aim, procedures and participants (NB: R= Respondent/Participant). benefits, and their rights as participants. The information and consent documents for participants were written in simple English. However, for better comprehension, research assistants were present during the informed consent process to 3.2. CHAT implementation opportunities explain any questions that the participants do not understand. Those consenting to participate either signed or placed a CHAT implementation opportunities were assessed both thumbprint on an informed consent form. All participants were during the campaign and afterwards in continuous distribution assured that the information they provided would be handled mode. These opportunities include sensitisation on the use of LLIN confidentially and research findings would be reported with and malaria prevention, as well as community participation in complete anonymity. CHAT activities were explored. Frontiers in PublicHealth 06 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 TABLE 1 Sociodemographic characteristics of participants. “CWC. We all do that because the volunteer also helps in Characteristic of participants Number of participants the organisation of the people.We entreat the pregnant woman to sleep under the mosquito net. We talk to them about the causes of Region malaria and that sleeping under the treated net will help prevent Eastern Region 27 malaria.” (R3, HoKpeta, Volta Region) Volta Region 16 In addition, the CHAT also engaged school children and Total 43 community members during religious gatherings, and this appears Sex to be a good platform because school children are likely to spread Female 18 information from the school to members of their households. Moreover, as Ghanaian communities are largely religious, it is a Male 25 good platform to communicate healthmessages. For instance, some Total 43 participants highlighted that Age “For the school, I talk to the kids about mosquito nets and 20–29 years 4 I ask them if their parents are using them and their response is 30–39 years 17 always yes. I think they were given just last year so according to 40–49 years 8 them, they are using it. So far, so good.” (R3, Tsito, Volta Region) 50+ years 14 Total 43 So far, we have been to schools to give education about the Educational Level prevention of malaria.” (R2, Kukurantumi, Eastern Region) Primary 2 JHS/Secondary/Middle School 10 “After our inauguration, it was almost in the festive season, Tertiary 31 that is Christmas, and the New Year was approaching, so we Total 43 decided to take that opportunity to meet the large crowd” [at various churches]. (R5, Apoli, Eastern Region) Marital Status Single 15 Married 28 “We educate them. When we go to church after we close, we also remind them on the use of the mosquito net and their Divorced/Widowed/Separated children under 5 years should also sleep under and also after Total 43 worship on Wednesdays.” (R4, HoKpeta, Volta Region) Home visitation is another effective way to communicate health messages to achieve desired behaviour changes. The findings further revealed that the CHAT engaged community members 3.2.1. Sensitisation on the use of LLIN and malaria on a one-on-one basis during home visits to educate community prevention members on the need to use the mosquito nets, so as to achieve the Findings from the study revealed that the CHAT was able intended purpose: to promote LLINs use and sensitise community members on malaria prevention strategies during and after the 2021 mass LLIN “As a community volunteer, when I am walking within the distribution campaign. The CHAT members provided education community and see they are using the net for the wrong purpose, on malaria prevention to various target groups such as mothers of I talk to them to use it the right way, sleep under it in order to children under five years, primary school children, and household prevent malaria.” (R2, HoKpeta, Volta Region) members. For instance, the CHAT provided mothers of children The study also showed that CHAT members under 5 years, at the CHPS level, with education on the proper use employed various SBCC channels in delivering malaria of LLINs and malaria prevention: messages to community members. Mediums, such as the community information centres (CIC) and banners, “We organised and have Child Welfare Clinic (CWC) every were mentioned. For instance, some participants time, there we demonstrated to the mothers how to use the net. mentioned that Because we got to know[sic] most of the kids are coming to the hospital with malaria, so[sic] we saw that the malaria cases are “We use the CIC, the local information centres. We have still going high with the kids now. It’s[sic] no more with the adults radio stations too-[sic] we engage them and durbars as well. Any much like that. So, we came to demonstrate to them how the gathering we get, we chip in and say something as well.” (R4, mosquito net is being used.” (R5, Tsito, Volta Region) Kukurantumi, Eastern Region) Frontiers in PublicHealth 07 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 “When we go, we educate with the SBCC materials as we of times it has been used that will show whether it is due to be said; our posters are showed[sic] to them as they see and they thrown away or not. So, they are now serious about the dump of remember.” (R6, Apoli, Eastern Region) the nets.” (R3, Achiase, Eastern Region) “With CIC Representative, you know he is into the “When we go for gathering and we announce that we are broadcasting and as a member, he took that one up and you coming and you see lots of the community members seated and know we don’t pay again to him and it’s the service to the during funerals and the outreach we had too, they were very community. So, every Wednesday, they do come for the early attentive and will do what we say.” (R2, Kpetoe, Volta Region) morning program. That is at 5:30 so by then people will wake up and listen to worship and after that, they come in mostly about Active participation in CHAT activities may have helped the mosquito net issue and the prevention of malaria... every change in behaviour among community members, as they observed Wednesday. Every Wednesday they do it unless maybe if[sic] improved understanding of malaria prevention and LLIN use. when there is no resource person on Wednesday.” (R1, Tsito, “The education we have been doing has been valued because Volta Region) when we visit the back of some houses, there is now neatness. Use of social media platforms could have been a faster Those we educated are now aware and now everyone is tidying way of promoting malaria prevention messages. However, some their surroundings up because dirt brings malaria so what we participants indicated that poor network access prevented use of have been educating has been valued and the elders have seen social media in some communities. it will help and their expenses will be cut short because a single mosquito bite can cause serious loss of income before you get “You see, there is no network here, so those who live here will healed[sic]. So, if the mosquito net can solve that problem, have difficulty in downloading and watching the video but those anytime, everyone should try and use the mosquito net. Malaria of us in Ho can easily view it.” (R3, Hokpeta, Volta Region) is reducing and we hope that it won’t be long for it to be curbed.” (R2, Achiase Eastern Region) “Yes, we have got many moments as we visit churches and 3.2.2. Community participation in CHAT activities gatherings where we have our health talk, misunderstandings The findings also revealed that there have been perceived about the[sic] malaria are being discussed as to the cause of changes within the various communities concerning malaria malaria as some are misinformed that malaria is from the sun.” prevention and LLIN use that can be attributed to the (R5, Apoli, Eastern Region) malaria education activities that the CHAT has been engaged in. For instance, some CHAT members mentioned that there has been a perceived reduction in malaria cases within “Some also said that malaria is brought by unripe mangoes the communities: so some people with these misconceptions, we speak to them to “In fact, in my place, it has been a long time now that I have inform them that it is mosquito bites that cause it.” (R8, Apoli, heard of malaria. Even in my room, my children are using it, Eastern Region) so that one is out. So, as we said, before we can see the actual result, it will be the statistics. But for me, we believe that even when you ask people. It’s just the young ones who are reluctant “What we can say is, OPD cases attendance has increased. in using it. But older adults and women are using it.” (R1, Tsito, So, with that, we can justify by saying that, maybe because of Volta Region) the sensitisation going on home management and those things are reducing and they are now visiting the facilities to seek In addition, there has been a positive reception from treatment.” (R6, Kpetoe, Volta Region) community members towards CHAT education activities on malaria prevention: “In schools, knowing the presence of this group, they are 3.3. CHAT implementation barriers paying more attention. The misuse of the nets is not good for both teachers and pupils. Also, we told them that there is a Some barriers that the CHAT faced within the four committee, like the security personnel, to cheque on the misuse months after their inauguration were discussed during the of the net. . .As we went to some school[sic, the children came discussions. For instance, some members said that the medium asking individually; if the net is torn and if it is used otherwise, of communication and active participation by members at CHAT they also will be caught?[sic] The madam continued that they meetings to plan and strategise activities have been a major will be interrogated about when they were given and the number challenge: Frontiers in PublicHealth 08 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 “We were using the WhatsApp page, and some people may “Like today as we were going to the school, we paid the fare not even have the data and even at Takla, the network is not all of the transport. The last time we went, we were supposed to go that good so we have to be calling everyone. So, it is very difficult.” in a group but already some were members so we had to pay for (R2, HoKpeta, Volta Region) the fare.” (R6, Kukurantumi, Eastern Region) Similarly, participants expressed the need for the provision of “Also, like the heads, every position has its duty to undertake refreshment during outreach activities as most of the outreach like ‘Madam A’, is part of us (CHAT). Like for the Friday[sic] activities take long hours and they need some water or food during she didn’t go to the farm. Saturdays, there are funerals, and on these outreaches. Sundays people go to church. She was supposed to go to the farm yesterday but there was another meeting she was supposed to “There is no addition really, but if you can be supporting us attend so she wasn’t able to [sic] join us (CHAT meeting). And small, small- at least water will do.” (R4, Hokepta, Volta Region) for me too, sometimes I have other tasks to take so I have to stop (the CHAT meeting) and attend the other meeting. So, these are “. . . and probably if we get something small like lunch the challenges we are facing.” (R2, Apoli, Eastern Region) or minerals, though they are adults but they know what they are doing so they are not demanding anything. So, they need “Yes, when you call for a meeting, not even a meeting, when something small to support them like small snacks like biscuits, you post something on the page, for people to respond to it, it that is our challenge.” (R4, Achiase, Eastern Region) becomes a problem. It is as a result [of lack] of motivation; that the motivation level has fallen. So, people feel like, I need to go “Also, we would be needing water and snacks so that somewhere to make (some money) than to have attention here so inclusive will help because some from morning do not eat when that is it...So I think being frank with you[sic], it will help all of going for education in the other towns. So at least, water should us.” (R3, Kpetoe, Volta Region) be provided.” (R7, Achiase, Eastern Region) Moreover, the need for some form of support in The need for some financial support in carrying out outreach terms of transportation to undertake outreach activities, activities was also mentioned. especially in hard-to-reach communities was mentioned by members. “Our main problem is the financial aspect where resources are needed like inviting professional resource personnel to come “Yes, going for programmes, there are some costs that come educate us, we need money to invite them too. Sometimes we with it such as the transportation and maybe feeding. All these volunteer and take on such tasks. . .we also plan to involve are on the individuals and sometimes, the Madam will have to other members like the midwives and some doctors so they can come in by buying water for the people. So, these are barriers and join in the education. But afterwards, we have to pay them, we need to fix them.” (R3, Kpetoe, Volta Region) which might turn into another challenge.” (R2, Kukurantumi, Eastern Region) “The main challenge now is our means of transport unless In addition, some CHAT members reported the need for like we were going round, I was the one who bought petrol to further instruction on transmitting messages to communities on all the six churches to the other places. Also, in other places, we malaria prevention and correcting LLIN misuse. Notably, some let them meet in a congregation, then I pick them up. Currently, indicated that the earth has also been challenging where you take someone out for hours and you don’t give them [sic]chance at their “I once met a lady like that, upon probing, she said, work, it feels bad though this is just the beginning of the team they are very old mosquito nets that are over 7 years but after that, everyone can return to their workplaces after old and are worn out and can’t be used, that is why, success. So, our challenge is as we are planning to visit another she used them for gardening/fencing. And I couldn’t say town like Aprade and other places, we need means for[sic] anything again because 7 years is a long time. So such transport to support as[sic] like getting us petrol so we don’t people too, what do we do to them[sic]?” (R3, Hokpeta, charge anything- we can just go and come back.” (R4, Achiase, Volta Region) Eastern Region) “I will say we need some motivation (e.g., capacity building) “. . . and like places like Yaw Agbo, going there, we have to in relation to the net distribution. Some people complain about take the motorbike and most of us don’t have the motorbike, so the net. Let’s say they are five (5) in the house and maybe only unless we hire and that also sometimes it’s hard to.” (R3, Apoli, two (2) were able to get the nets so the rest explain to them that Eastern Region) okay maybe there was distribution in the various schools so when Frontiers in PublicHealth 09 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 the child gets it in the school, they can use it at home. So, we need during these outreaches. These findings are consistent with other to know it and explain [sic]to them so that every household can studies conducted in other parts of Africa, where a lack of financial get it.” (R1, Kpetoe, Volta Region) support is reported to impede the delivery and sustainability of health volunteer work (25–27). 4. Discussion 5. Limitation This study explored the opportunities (LLINs use and malaria Although this exploratory study of the opportunities and prevention strategies, community participation in CHAT activities) barriers in the pilot implementation of the CHAT provides some and implementation barriers to the pilot implementation of the co- useful lessons, the four-month duration of the pilot implementation created CHAT. These teams seek to integrate the LLIN distribution is relatively short to unravel all possible lessons. There is a need for campaigns with the CHPS programme to promote community further scale-up beyond the six pilot districts in Ghana to assess LLIN ownership and use both during and beyond campaigns its effectiveness and impact with respect to LLINs promotion and in Ghana. This study has yielded important findings that will use. Moreover, due to the seasonality of malaria transmission in help provide the CHATs with the necessary support to effectively Ghana (i.e., during rainy seasons—April to June and September to perform their roles and address barriers. The findings can also November), the season within which the CHAT was implemented inform further scaling-up of the CHATs across Ghana. could also influence the opportunities and barriers realised; hence, The study showed that CHAT members engaged different there is the need for long-term implementation of the CHAT to groups of the population during their malaria prevention effectively observe the seasonal variations of opportunities and sensitisation. The CHAT members employed SBCC strategies to barriers of CHAT in promoting LLIN use and malaria prevention. educate them on the continuous use of the treated mosquito nets. As evidence suggests, the use of SBCC can improve malaria prevention and treatment behaviours (10, 17). The employment 6. Conclusion of various mediums (e.g., community information centres) and platforms (e.g., child welfare clinics, schools, religious gatherings, The community health advocacy teams have a great promise to and door-to-door visits) serves as a means of reaching a larger sustain community LLIN promotion activities both during PMD population with malaria prevention messages which will help campaigns and afterwards in relation to the primary healthcare contribute to achieving sustainable outputs and impacts concerning system in Ghana. In order for this to happen, there is the need malaria control in Ghana (18–21). to address barriers to the effective functioning of the CHATs, Community reception is key to achieving desired health including the provision of financial support to aid transportation, behaviours (20). The study revealed that community members were the provision of refreshments and support for their outreach receptive to the CHAT members whenever they were carrying activities, the provision of financial motivation to increase their out malaria sensitisation activities. Moreover, community members level of participation in CHAT activities, and the provision of good became better informed about the causes of malaria, malaria network access to address their communication barriers. Finally, prevention strategies, as well as the use of LLINs for the intended CHATmembers require continuous capacity building, especially in purpose. Community members were also taught how to properly use of SBCC to promote LLIN access and use, to most effectively hang the nets regardless of housing style or sleeping places. Possible support the PMD and to transition LLIN distribution to routine or positive changes in community behaviour are very important as continuous channels through CHPS. they address some barriers to LLIN use that have been realised in earlier studies such as limited use of SBCC activities, lack of Data availability statement continuous malaria education (5, 22–24), knowledge gap at the community level on malaria prevention, inability to hang LLINs in The raw data supporting the conclusions of this article will be many household types and sleeping places, and the misuse of nets made available by the authors, without undue reservation. (6, 7). Access to accurate information about malaria can promote increased use of LLINs and reduce the gap between LLIN access to and use eventually contributing to the reduction in malaria Ethics statement morbidity and mortality. The studies involving human participants were reviewed and Although the pilot implementation of the CHAT has achieved approved by Ghana Health Service Ethics Review Committee. The many successes, it encountered several barriers. Most of these patients/participants provided their written informed consent to barriers revolved around financial support in carrying out participate in this study. voluntary activities. Although the CHAT has been set up as a voluntary team without any remuneration, there were situations where they needed financial resources to carry out LLIN and Author contributions malaria sensitisation activities. Some of these activities include transportation to neighbouring communities or hard-to-reach PD-G, FG, EA, PT, and ANwere in charge of conceptualisation, areas of communities as well as providing refreshments after data curation, formal analysis, methodology, and original draft. community outreach activities, as they usually spend long hours RH supported with data analysis, methodology, and drafted the Frontiers in PublicHealth 10 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 manuscript. PA and DG reviewed and revised the final draft. West, Ho, Agortime Ziope, Birim South, Achiase, and Abuakwa All authors participated in designing the study with NP and GC North districts, CHAT members, as well as community members, providing technical support. All authors contributed to writing the who committed time to share experiences and provide data for this manuscript and approved the final draft. study. They are also grateful to the field staff for their meticulous work during data collection. Funding Conflict of interest This work was supported, in whole or in part, by the Bill and Melinda Gates Foundation (Grant Number INV-01076 to the Task The authors declare that the research was conducted in the Force for Global Health’s Health Campaign Effectiveness Program). absence of any commercial or financial relationships that could be Under the grant conditions of the foundation, a Creative Commons construed as a potential conflict of interest. Attribution 4.0 Generic License has already been assigned to the author accepted manuscript version that might arise from this submission. Publisher’s note Acknowledgments All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated We would like to thank all stakeholders: members and staff organizations, or those of the publisher, the editors and the from the Ghana Health Service (GHS) and the National Malaria reviewers. Any product that may be evaluated in this article, or Elimination Programme (NMEP), the Volta and Eastern Regional claim that may be made by its manufacturer, is not guaranteed or Directors of Health Services, the District Health Directors of Ho endorsed by the publisher. References 1. World Health Organization. Guidelines for Malaria Vector Control. Geneva: of health systems strengthening on maternal & child survival. BMC Health Serv Res. World Health Organization (2019). (2013) 13:1–12. doi: 10.1186/1472-6963-13-S2-S3 2. Dzata ST, Coleman N, Quakyi I. Coverage and use of long-lasting insecticide 15. Glozah F, Asampong E, Tabong PT-N, Nwameme A, Hornuvo R, Chandi treated nets in Kpone-on-Sea Township, Accra, Ghana: a cross-sectional study. Heal M, et al. Creating interventions to transition long-lasting insecticide net Sci Investig J. (2020) 1:57–63. doi: 10.46829/hsijournal.2020.6.1.1.57-63 distribution in Ghana. BMJ Open. (2022) 12:e063121. doi: 10.1136/bmjopen-2022-0 63121 3. Ghana Statistical Service (GSS) and ICF. Ghana Malaria Indicator Survey 2019. Accra; Rockville, MD: GSS and ICF (2020). 16. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. (2006) 3:77–101. doi: 10.1191/1478088706qp 4. WHO U. Achieving the Malaria MDG Target: Reversing the Incidence of Malaria 063oa 2000–2015. Geneva: World Heal Organ. (2015) 17. Koenker H, Keating J, Alilio M, Acosta A, Lynch M, Nafo- 5. Worrall E, Were V, Matope A, Gama E, Olewe J, Mwambi D, et al. Traore F. Strategic roles for behaviour change communication in a Coverage outcomes (effects), costs, cost-effectiveness, and equity of two combinations changing malaria landscape. Malar J. (2014) 13:1–4. doi: 10.1186/1475-2 of long-lasting insecticidal net (LLIN) distribution channels in Kenya: a two- 875-13-1 arm study under operational conditions. BMC Public Health. (2020) 20:1– 16. doi: 10.1186/s12889-020-09846-4 18. Briscoe C, Aboud F. Behaviour change communication targeting four health behaviours in developing countries: A review of change techniques. Soc Sci Med. (2012) 6. Opoku R, Amoah PA, Nyamekye KA. Householders’ perception about sustaining 75:612–21. doi: 10.1016/j.socscimed.2012.03.016 the useful life of long-lasting insecticide-treated nets in Ghana. Int Health. (2021) 13:57–62. doi: 10.1093/inthealth/ihaa019 19. Jagosh J, Macaulay AC, Pluye P, Salsberg JON, Bush PL, Henderson JIM, et al. Uncovering the benefits of participatory research: implications of 7. Bannor R, Asare AK, Sackey SO, Osei-Yeboah R, Nortey PA, Bawole JN, et al. a realist review for health research and practice. Milbank Q. (2012) 90:311– Sleeping space matters: LLINs usage in Ghana. Pathog Glob Health. (2020) 114:271– 46. doi: 10.1111/j.1468-0009.2012.00665.x 8. doi: 10.1080/20477724.2020.1776920 20. Ghosh SK, Patil RR, Tiwari S, Dash AP. A community-based health 8. Assan A, Takian A, Aikins M, Akbarisari A. Universal health coverage education programme for bio-environmental control of malaria through folk necessitates a system approach: an analysis of Community-based Health theatre (Kalajatha) in rural India. Malar J. (2006) 5:1–7. doi: 10.1186/1475-28 Planning and Services (CHPS) initiative in Ghana. Global Health. (2018) 75-5-123 14:1–10. doi: 10.1186/s12992-018-0426-x 21. Leask CF, Sandlund M, Skelton DA, Chastin SFM. Co-creating 9. Malede A, Aemero M, Gari SR, Kloos H, Alemu K. Barriers of persistent long- a tailored public health intervention to reduce older adults’ sedentary lasting insecticidal nets utilization in villages around Lake Tana, Northwest Ethiopia: a behaviour. Health Educ J. (2017) 76:595–608. doi: 10.1177/00178969177 qualitative study. BMC Public Health. (2019) 19:1–11. doi: 10.1186/s12889-019-7692-2 07785 10. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change 22. Scott J, Kanyangarara M, Nhama A, Macete E, Moss WJ, Saute F. Factors health behaviour. Lancet. (2010) 376:1261–71. doi: 10.1016/S0140-6736(10)60809-4 associated with use of insecticide-treated net for malaria prevention in Manica 11. Dako-Gyeke P, Amazigo U V, Halpaap B, Manderson L. Social innovation for District, Mozambique: a community-based cross-sectional survey. Malar J. (2021) health: engaging communities to address infectious diseases. Infect Dis Poverty. (2020) 20:1–9. doi: 10.1186/s12936-021-03738-7 9:1–4. doi: 10.1186/s40249-020-00721-3 23. Aberese-Ako M, Magnussen P, Ampofo GD, Tagbor H. Health system, socio- 12. Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, Miller RA. The cultural, economic, environmental and individual factors influencing bed net use in Ghana community-based health planning and services initiative for scaling up service the prevention of malaria in pregnancy in two Ghanaian regions. Malar J. (2019) delivery innovation. Health Policy Plan. (2005) 20:25–34. doi: 10.1093/heapol/czi003 18:1–13. doi: 10.1186/s12936-019-2994-5 13. Binka FN, Nazzar A, Phillips JF. The Navrongo community health and family 24. Baltzell K, Harvard K, Hanley M, Gosling R, Chen I. What is community planning project. Stud Fam Plann. (1995) 121–39. doi: 10.2307/2137832 engagement and how can it drive malaria elimination? Case studies and 14. Awoonor-Williams JK, Bawah AA, Nyonator FK, Asuru R, Oduro A, Ofosu A, stakeholder interviews Malar J. (2019) 18:1–11. doi: 10.1186/s12936-019- et al. The Ghana essential health interventions program: a plausibility trial of the impact 2878-8 Frontiers in PublicHealth 11 frontiersin.org Dako-Gyeke et al. 10.3389/fpubh.2023.1133151 25. Perry HB, Zulliger R, Rogers MM. Community Health Workers qualitative study on the role of on-site supervision in the South African programme. in Low-, Middle-, and High-Income Countries: An Overview of Their BMJ Open. (2019) 9:e022186. doi: 10.1136/bmjopen-2018-022186 History, Recent Evolution, and Current Effectiveness. (2014) 35:399– 27. Lusambili AM, Nyanja N, Chabeda SV, Temmerman M, Nyaga L, Obure J, et al. 421. doi: 10.1146/annurev-publhealth-032013-182354 Community health volunteers challenges and preferred income generating activities 26. Tseng YH,Griffiths F, DeKadt J, NxumaloN, Rwafa T,Malatji H, et al. Integrating for sustainability: a qualitative case study of rural Kilifi, Kenya. BMC Health Serv Res. community health workers into the formal health system to improve performance: a (2021) 21:642. doi: 10.1186/s12913-021-06693-w Frontiers in PublicHealth 12 frontiersin.org