Out of the 39 published articles that were considered for the design, 19 articles were selected for inclusion. Of these, 11 articles were of sufficient quality to be examined further although they showed minor concerns in the formal assessment of methodologies, relevance, coherence, and adequacy of data based on the GRADE-CERQual approach [Table 1]. The fundamental components of the CoCoPOPP were developed based on the outcome of the systematic review. Thereafter, the components were mapped to the framework of PARIHS, with components reaching high ratings in terms of the evidence (research, professional experience, and community preference), context (culture, leadership, and evaluation), and facilitation (characteristics, role, and style of the facilitators) features [Table 2].
Table 1
List of articles on epidemic analysed for CoCoPOPP
Article
|
Meth Limit.
|
Relevance
|
Coherence
|
AdEq. of Data
|
OCAoF
|
Frimpong & Paintsil (2020) Ebola40
|
MC
|
MC
|
MC
|
MC
|
HC
|
Coltart et al (2017)- Ebola41
|
MC
|
MC
|
MC
|
MC
|
MC
|
Kirsch et al (2017); Ebola42
|
MC
|
MC
|
MC
|
MC
|
MC
|
Cornish et al (2014); HIV/AIDS43
|
MC
|
MC
|
MC
|
MC
|
MC
|
Salam et al (2014); HIV/AIDS44
|
MC
|
MC
|
MC
|
MC
|
MC
|
McLean et al (2018); Ebola45
|
MC
|
MC
|
MC
|
MC
|
HC
|
Abramowitz et al (2018, 2017, 2015); Ebola46 47
|
MC
|
MC
|
MC
|
MC
|
HC
|
Sambala et al (2019); Influenza48
|
MC
|
MC
|
MC
|
MC
|
HC
|
WHO Ebola Response Team (2018)49
|
MC
|
MC
|
MC
|
MC
|
HC
|
Note: Methodological limitations (Meth Limit); Adequacy of Data (Adeq. of Data) Overall CERQUAL Assessment of Confidence (OCAoF); Minor Concerns (MC); High confidence (HC). Source: Compiled from CoCoPOPP implementation document, 2020
Table 2
Stakeholders involved in the implementation of CoCoPOPP
Primary stakeholders
|
Secondary Stakeholders
|
Community leaders (Chief and elders, Village Committee)
Community members
Cocoa360 executives and directors
TBCC healthcare workers
Cocoa360 Research Team
Social mobilizers
Community liaison
Information flow manager
Data collectors
TBCHPS
|
University of Ghana
Ghana Ministry of Health (MoH)
Vanderbilt University
Yale University
Donors
|
Source: Compiled from CoCoPOPP implementation document, 2020
Satisfying PARIHS’ Evidence in the design of CoCoPOPP
The intervention was scientifically robust because it relied on the research of published sources, matched professional opinion reached by the group as a whole, and met the needs of the TB and its surrounding communities. The intervention was able to meet the needs of the target communities because it depended on community perspectives and routine information derived from the members of the communities.
The study also relied on the expert opinions and experiences of professionals. Physicians and clinical practitioners from GHS—PHVHD, TBCC, and TBCHPS—who understand the socio-cultural dynamics, disease prevalence, demographics, and health care needs, and services utilization of the communities were part of the design team. They shared their consensus opinions through the participatory effort of the design process. CoCoPOPP’s design was driven by evidence given that information derived from research, clinical experience, and local practical context were respectively from robust methodology (such as randomized controlled trial (RCT)), consensus and met community needs [Table 3].
Satisfying PARIHS’ Context in the design of CoCoPOPP
The design of CoCoPOPP was highly sensitive to the needs of the target population. This was done by taking into account the communities' culture while considering the leadership, monitoring, and feedback systems in the participating rural communities.
The intervention was designed to meet the cultural dynamics of the communities. As part of the implementation strategy, it was specified that:
CoCoPOPP will first be presented to the Chief and elders of TB for feedback, support and suggestions. Also request that a Community Leader (preferably the local Chief) announce CoCoPOPP to the community, highlighting the community’s risk, and the intervention’s potential impact, and encouraging interested residents to sign up for social mobilization roles.28
The implementation strategy gave a more significant mandate to the chief and elders (who are the custodians of the communities) to approve of the intervention before it was unveiled for implementation. Hence, the following was documented in the design of the implementation strategy:
After approval from community leaders and Cocoa360’s VC, we shall secure the necessary logistics.28
The intervention was designed to ensure that the community leads and champions the communication aspect of the intervention.
Request Community Leaders to Champion CoCoPOPP: Take the lead on telling the community about CoCoPOPP and cultivating their support.28
Moreover, the design of the intervention-implementation strategy also ensured that the community members did not only benefit from the intervention but also took active roles in the implementation process and were treated as experts [see excerpts from the intervention document below].
Requesting community leaders (preferably the local Chief and VC) to encourage interested residents to sign up for social mobilization roles…; and All participants recruited for the surveys and focus group discussion are treated as experts.28
The study ensured that all participants were respected and treated as experts, reimbursed their traveling costs (if any), received souvenirs (such as prepaid phone cards after interview /focus discussions) or gifts that might be useful for the participants in the context of the cultural norms of the communities instead of cash. The issues of acceptability, trust, recognition, and respect were minimized by engaging the community leaders and VC in introducing CoCoPOPP to the communities. Moreover, the recruitment announcement of CoCoPOPP was first delivered by local leaders at a community meeting. Similarly, community leaders were included in the discussions to promote community members’ participation.
CoCoPOPP also included educating the population and promoting learning in the communities themselves; conducting research to collect data to try new and different techniques for organizational use; and sharing insights on epidemic management and control with the Ghanaian government, wider global health and education community [see excerpts from the intervention document below].
The intervention presents a strong opportunity to conduct research and gain insights on epidemic management and control with the Ghanaian government and the wider global health and education community. This will be an extremely crucial resource for the control and management of future epidemics in similar settings.28
All these implementation measures guaranteed that CoCoPOPP was effective in minimizing the spread of COVID-19 in the community while following the cultural dynamics of the people [Table 3].
CoCoPOPP was designed to ascertain clear roles and objectives among the stakeholders [Table 2] involved in the intervention. The stakeholders within each group worked together as a team and shared power. For instance, TBCC healthcare workers worked closely with each other and had general authority in treating their clients. Each of the micro teams was coordinated by the Cocoa360 managers to ensure harmony and good communication among the teams. A high sense of leadership characterized CoCoPOPP’s design because of the clearly defined roles, responsibilities, objectives, and effective coordination specified for each of the stakeholders and among the various team units [Table 3].
Evaluation is one of the key fulcrums CoCoPOPP leverages on; where the intervention strategy allowed for interdisciplinary investigators from Yale University, Vanderbilt University, University of Ghana, MoH, GHS, and Cocoa360 to participate in monitoring and evaluation efforts. Below is an excerpt from the implementation strategy, elaborating how CoCoPOPP was consistent with the PARIHS framework’s sub-element evaluation.
A strong team of interdisciplinary investigators at the University of Ghana, and Yale University in partnership with (MoH) (GHS), Cocoa360, and VC shall research to monitor and evaluate the CoCoPOPP intervention.28
The intervention package further allowed for data collection before, during, and after implementation, to measure the effectiveness of all possible activities and outcomes. Likewise, the intervention design also factored in all the necessary metrics to estimate the possible individual and team performance, activities, outputs, outcomes, and impact of the intervention. CoCoPOPP also emphasized feedback on individual, team, and the intervention performance on the community;
Consistent with our community engagement principles as an organization, we will continue to update VC and community chiefs and elders about progress → materials distributed; cases being see.28
The robustness and consistency of evaluation (that is, the presence of routine monitoring systems) throughout the phases of CoCoPOPP can be described as high based on the concept of the PARIHS framework [Table 3].
Table 3
CoCoPOPP satisfying PARIHS framework elements and sub-elements
Elements
|
Sub-element
|
Rating
|
Evidence
|
Research
|
High
|
|
Professional (Clinical) Experience
|
Moderate
|
Community preference
|
High
|
Context
|
Leadership
|
High
|
|
Culture
|
High
|
Evaluation (Measurement)
|
High
|
Facilitation
|
Characteristics of facilitator
|
High
|
|
Role of facilitator
|
High
|
Style of facilitator
|
High
|
Source: Compiled from CoCoPOPP implementation document, 2020
Satisfying PARIHS Facilitation in the design of CoCoPOPP
Facilitation is an element in the PARIHS framework, a function of implementation success and is influential in overcoming the barriers to evidence-based practice.29 The designers of CoCoPOPP took facilitation into account in the design process by soliciting inputs from relevant internal and external facilitators. Internal facilitators include community leaders (chief and elders, VC), Cocoa360 executives, TBCC healthcare workers, social mobilizers, Cocoa360’s research team, and data collectors while the external facilitators were representatives from the Yale University, Vanderbilt University, University of Ghana, and MoH. These facilitators exhibited characteristics consistent with that of opinion leaders, change agents, champions, educational outreach workers, and linking agents in the implementation strategy to promote high facilitation.
With regards to the facilitation of CoCoPOPP, the chief and elders are the opinion leaders from the local communities. The communities view them as highly credible, respected sources of influence (via authority, status, and representativeness). The VC helped to coordinate implementation synergy between Cocoa360 and members of the participating communities. Lastly, Cocoa360’s executives, TBCC healthcare workers, and Cocoa360’s research team, social mobilizers, and data collectors were the internal change agents who promoted and ensured CoCoPOPP’s successful implementation. Internal change agents have strong interpersonal and communication skills, are knowledgeable and understanding, and have earned the trust and respect of the community because of their consistent interaction with the community for at least two years. The external facilitators of CoCoPOPP are educational outreach workers; they are topic experts that are external to the intervention setting and knowledgeable about their area of specialization. They met with other facilitators to provide useful information about the evidence-based intervention and provide feedback when necessary.
These skilled facilitators had clearly defined roles to achieve a specific objective in the practice of CoCoPOPP and to ensure consistency in the delivery process. Facilitators, especially those who were directly involved in the intervention’s success, had experience of at least two years in the environment of the intervention area and were fully aware of the possible challenges they were likely to face, hence were flexible, showed empathy when dealing with the people, and were tenacious in overcoming challenges. Thus, CoCoPOPP’s design considered high facilitation [Table 3] of change with input from adept internal and external facilitators.