Engaging and empowering communities in responding to COVID-19 in low resource countries: A case study of Ghana

The control of epidemics and pandemics such as the coronavirus disease 2019 (covid-19), remain a challenge to the global community's efforts toward achieving the set targets of sustainable development goal 3 (SDG 3) - ensure healthy lives and promote wellbeing for all at all ages (Galati, 2015, Sundewall and Forsberg, 2020, United Nations, 2020). Even more developed countries, which were thought to have stronger health care systems have experienced challenges in their response to covid-19. The effect of global pandemics tend to be greater on Sub Saharan Africa, because of limited workforce and other resources available to already overstretched and weak health care systems. Additionally, poverty, illiteracy, ignorance, socio-cultural beliefs and practices are rife. Such factors contributed to community distrust of the health care system and sometimes poor cooperation resulting in high rates of infections and the loss of several thousand lives in the Ebola outbreak in Sierra Leone, Liberia and Guinea in 2014 - 2015 (Phillip, 2014, Wang et al., 2020). Sub Saharan African countries like Ghana need to strengthen community engagement and empowerment in health delivery, to ensure early and timely delivery of services, curbing widespread infections, reducing stress on health care systems and saving lives, which will accelerate achievement of SDG3 (Hanson et al., 2017). Ghana introduced the community-based health planning and services (CHPS) concept in 1997, to support its relatively weak health care system. The aim of CHPS is to mobilize community leadership, decision making systems and resources in a defined catchment area, the placement of reoriented frontline health staff with logistic support and community volunteer systems to provide services according to the principles of primary health care (Frimpong, 2020). Subsequently the Ghana Health Service and its partner organisations have established CHPS compounds in most districts in Ghana to offer primary health care in communities. The CHPS facilities are under the Ghana Health Service, which is the government's health service provision agency. Currently, Ghana has 1,550 convid-19 cases with 10 deaths (Ghana Health Service, 2020a). Government's strategy in combatting covid-19 include closure of Ghana's boarders with her neighbours, general surveillance, enhance contact tracing, health education and treating cases (Ghana Health Service, 2020b). There have been anecdotal reports of developments that are currently hampering government's efforts in combating covid-19 such as resistance of community members to contact tracing and testing. Stigmatization of covid-19 victims and survivors and outright refusal by some communities to allow government to use public buildings sited in their locality as quarantine centres (Darko, 2020, Ghana Web, 2020a, Ghana Web, 2020c). Also, community leaders have bemoaned government's failure to engage them in the fight against covid-19 (Ghana Web, 2020b). This raises concerns on why government's efforts at using CHPS to engage and empower communities has not yielded the desired results in the fight against covid-19. 2) Aims or research questions being addressed Research Goal To explore and understand how the Ghana health service has engaged and empowered communities to support the fight against convid-19. Specific objectives • To understand how the Ghana Health Service has engaged and empowered communities in the fight against covid-19 • To understand the gaps in the engagement and empowerment efforts of communities in the fight against convid-19 • To explore innovative ways that the Ghana Health Service can employ to improve engagement and empowerment of communities to respond to the fight against covid-19 and other infectious diseases Research questions • How has the government engaged and empowered communities in the fight against covid-19? • What have they engaged communities on? • What has been the response of communities? • How can the challenges in engaging and empowering communities be addressed to support their work? 3) Study design The study design will be ethnographic using indepth interviews (IDIs), focus group discussions and observations in two communities. Ethnographic qualitative design is the appropriate approach for this study, as the study seeks to understand behaviours such as communities' interactions with the Ghana health system, communities' experiences in empowerment processes and their response to the fight against covid-19 (Patton, 2002). Two communities with CHPS compounds would be purposively selected for the study and one community under each CHPS compound will be purposively selected for the study. In each CHPS compound two frontline staff will be purposively selected to participate in the IDIs. Two Ghana Health Service managers from the study district will be included in the study. Twenty-four IDIs will be conducted, 12 in each community with chiefs, elders etcetera (the list below gives the breakdown). They will be purposively selected for face-to-face IDIs, which will seek to understand how the health system has engaged and empowered communities in the fight against covid-19. Focus group discussions will be conducted with women, men and adolescents on the same theme. The focus group discussions would consist of 6 to 13 participants, who would be purposively selected to participate. Participation will be voluntary and those who are not interested would be automatically excluded, as well as those who are mentally challenged. Observations would be carried out in key public places to identify community resources. List of data collection methods and categories of respondents Ghana Health Service level IDIs FGDs District officials 2 - Frontline staff 4 - 2 Communities Chiefs 4 - Elders 4 - Women - 4 Men - 4 Young people - 4 Religious leaders 4 - Herbalists 4 - Assembly persons 4 Total 28 16 The study will be conducted in the Ketu South Municipality of the Volta Region of Ghana, because currently it has the highest number of 6 out of the 10 covid-19 cases in the region. The Municipality also shares boundaries with the Republic of Togo to the east, which makes it to a very interactive district. The population of the Municipality according to 2010 population and housing census stands at 160,756 with 75,648 males and 85,108 females (Ministry of Local Government and Rural Development, 2006, Wikipedia, 2019). Data management Interviews and observation notes will be recorded using a digital recorder. The recorders and the transcribed data will be anonymized and accessible only to the study team and will be used only for the purposes of the study. After the study the anonymized data sets would be uploaded onto the UHAS data sharing portal and will be made available to students for academic work. Data analysis: Transcribed data (IDIs, FGDs, observation notes) will be uploaded onto a computer and transferred onto qualitative software NVivo 12 to support data coding and analysis. Thematic analysis will be conducted, which will form the basis of reporting study results. Ethical issues: All ethical procedure will be followed. The protocol will be submitted to the University of Health and Allied Sciences' ethics review committee for approval. Selection and participation in the study will be purely voluntary. 4) Approach used to maximise the impact of research outputs, to improve health and the research community The approach that would be used to maximise research output will be as follows: • Publication of at least two articles from the study in open access journals • Development of policy briefs that will be shared with the Ghana Health Service, CHPS compounds, the department of infectious diseases of Ghana and it will also be posted on the Institute of Health Research of the University of Health and Allied Sciences website • The study results will be disseminated at local and international conferences • Durbars, which are open air meetings, will be organized to share the results with community members • Dissemination workshops would be held with health workers and managers in the study district to share the findings with them • The results would be presented at the Institutes' monthly technical meetings 5) Expected outcomes The following are the expected outcomes: • The results will contribute to understanding the extent to which the government has engaged and empowered communities in the fight against covid-19 • Challenges in community engagement and empowerment would be identified and recommendations to address them would be proposed • The results would reveal community response to government's engagement and empowerment efforts in their fight against epidemics and global pandemics such as covid-19 in Ghana • The results will unearth strategies to strengthening engagement and empowerment of communities to support the Ghana health care system in fighting diseases such as covid-19 within communities • The results could support policy revisions of community engagement and empowerment approach currently being applied in Ghana 6) Your role in the project The study will involve a team of five researchers: a supervisor, a principal investigator and three field assistants. My role will be the principle investigator, which will include designing the study protocol and study guides, training of field assistants, leading the research team in data collection, analyzing the data gathered, drafting the results into publications, developing policy briefs and presentations and writing and coordinating the dissemination process. I will also liaise with the funders to update them on the developments of the study. Selected reference DARKO, K. A. 2020. 2 Covid-19 patients at Old Fadama on the run [Online]. Accra: Joy Online. Available: https://www.myjoyonline.com/news/national/2-covid-19-patients-at-old-fadama-on-the-run/ [Accessed 12/04/2020 2020].