TYPE Original Research

PUBLISHED 31 July 2023

DOI 10.3389/fpubh.2023.1133151

Pilot implementation of
OPEN ACCESS community health advocacy
teams to improve the
EDITED BY
Manuela Berto Pucca,
Sáo Paulo State Universty, Brazil

REVIEWED BY
Altair Seabra de Farias,
effectiveness of long-lasting
University of the State of Amazonas, Brazil
Praveen K. Bharti,
National Institute of Malaria Research
insecticide net distribution
(ICMR), India

*CORRESPONDENCE
through both campaigns and
Franklin N. Glozah
fglozah@ug.edu.gh continuous channels in Ghana: a
RECEIVED 28 December 2022
ACCEPTED 07 July 2023
PUBLISHED 31 July 2023
qualitative study of opportunities
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
community health advocacy teams to improve
Phyllis Dako-Gyeke1 , Ruby Hornuvo1 , Franklin N. Glozah1*,
the effectiveness of long-lasting insecticide net Emmanuel Asampong1 , Philip Teg-Nefaah Tabong1 ,
distribution through both campaigns and
continuous channels in Ghana: a qualitative Adanna Nwameme1 , Gloria. M. Chandi2 , Nana Yaw Peprah3 ,
study of opportunities and barriers to
implementation.
David Gittelman4 and Philip B. Adongo1
Front. Public Health 11:1133151. 1
Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, Accra,
doi: 10.3389/fpubh.2023.1133151 Ghana, 2 Ghana Health Service, Ga North Municipal Health Directorate, Accra, Ghana, 3 National Malaria
COPYRIGHT Elimination Programme, Accra, Ghana, 4 Health Campaign Effectiveness 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 effective
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 effectiveness 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 effectiveness 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 Public Health 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: The CHATs would 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). The World 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 Public Health 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 Abuakwa North (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 Public Health 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, CHAT members, 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 Public Health 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 Public Health 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 Public Health 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.
Male 25
Moreover, as Ghanaian communities are largely religious, it is a
good platform to communicate health messages. 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 Public Health 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 Public Health 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 Public Health 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 CHAT members 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.
Although the pilot implementation of the CHAT has achieved The studies involving human participants were reviewed and
many successes, it encountered several barriers. Most of these approved by Ghana Health Service Ethics Review Committee. The
barriers revolved around financial support in carrying out patients/participants provided their written informed consent to
voluntary activities. Although the CHAT has been set up as a participate in this study.
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 AN were 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 Public Health 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 Public Health 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, De Kadt J, Nxumalo N, 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 Public Health 12 frontiersin.org