Skip to main content

Development of a community-based COVID-19 intervention in rural Ghana: a document analysis



The COVID-19 pandemic has caused the loss of millions of lives and economic breakdowns in many countries across the globe. Despite the limited availability of vaccines and the challenges of poor health infrastructure, few interventions have been developed and implemented for those who live in rural areas, particularly in sub-Saharan Africa. In response, Cocoa360, a global health nonprofit in rural Ghana designed an intervention called Cocoa360’s COVID-19 Preparedness and Outbreak Prevention Plan (CoCoPOPP). This paper aimed to examine the extent to which CoCoPOPP’s design aligned with the Promoting Action on Research Implementation in Health Services (PARIHS) framework.


We reviewed documents influencing CoCoPOPP’s design between March and June 2021. A total of 11 documents were identified for analysis. Using the Promoting Action on Research Implementation in Health Services (PARIHS) framework as a guide, thematic analysis was done to analyze the extracted data.


Overall, CoCoPOPP’s design aligned with the evidence, context, and facilitation domains of the PARIHS framework. It positioned CoCoPOPP as an intervention that considered the unique context of a rural Ghanaian setting. It was guided by robust and high-quality published and non-published evidence and engaged external and internal stakeholders during its implementation. CoCoPOPP’s context-dependent nature positions it for potential replication in sub-Saharan Africa’s rural communities with similar farming contexts. Specific areas that were less well and/or not addressed were the unintended negative consequences of community engagement, the absence of primary data in the guiding evidence, and the lack of a facilitation continuum coupled with the role of power during the facilitation process.


CoCoPOPP, Cocoa360’s response to the COVID-19 pandemic in rural Ghana, is an evidence-driven, context-dependent public health intervention that has been designed to reduce COVID-19 infections and prevent potential deaths. This study underscores the importance of considering the unique community and cultural contexts, employing evidence, and engaging local and external actors as facilitators when designing interventions to respond to global health pandemics.

Peer Review reports


The coronavirus disease 2019 (COVID-19) has thrown the entire world into disarray – hundreds of thousands of lives have been lost, economies have come to a halt, and the urgency to stop its spread has grown daily. In March 2021, over 123 million COVID-19 cases had been confirmed worldwide, of whom 69.9 million people have recovered, and 2.7 million have died [1]. Although the USA, India and Brazil have been the most affected countries, low-and-middle-income countries in sub-Saharan Africa continue to experience surges in infections. Notably, the continent has recorded over 4 million confirmed cases (with South Africa being the most drastically affected country), 3.57 million recoveries, and an estimated 106,280 deaths [2]. Ghana, one of the African nations with a relatively high incidence of COVID-19 (in the top 10), has confirmed nearly 90,000 cases, 86,000 recoveries, and a little over 700 deaths as of mid-March 2021 [3]. Yet, with under a million people tested out of the country’s 30 million population, these numbers are just a small percentage [3].

Evidence on actual COVID-19 occurrence in the populations of Ghana and other African countries will be highly underestimated, and existing civic systems cannot capture the scale of community transmissions, particularly in rural areas [4]. Rural communities in developing countries are considerably more vulnerable to COVID-19 than urban areas [5, 6] because the population is relatively older [7]. Economic pressures, out-migration of the young and return of retirees have all been shown to contribute to this ageing of rural communities [7,8,9,10]. Coupled with the high prevalence of comorbidities such as diabetes, cardiovascular diseases, and lung diseases, these economic and migratory pressures exacerbate the potential impact of the pandemic in these communities [11, 12]. The healthcare challenges posed by the COVID-19 pandemic are a significant concern for rural areas, where over 70% of Ghana’s rural population already struggle to access healthcare [4].

Given the diversity of demographic, socio-cultural and economic circumstances across nations of the world, and those recommendations from the World Health Organisation (WHO) are framed at a global level, each country and locality must contextualize and adapt WHO’s recommendations [13]. The reality of such contextual differences has resulted in in-country innovations and adaptations to the pandemic response, including local solutions such as mobile-driven self-diagnosis applications, an X-ray-based self-screening platform, mobile-based screening and mapping tools, low-cost methods for the production of personal protective equipment (PPE) being implemented across sub-Saharan Africa [13]. Such innovation, driven by urgent need and mostly without in-built evaluation, highlights how important it is to generate evidence on effective community-specific interventions to control the spread of COVID-19 and alleviate its impact on health and socio-economic conditions for rural citizens. In Ghana, the government has provided scant support to rural communities [4]. During the COVID-19 pandemic, this situation has not changed, and the COVID-19 prevention and control efforts in most rural areas in Ghana and other developing countries have fallen short of in their capacity to improve health outcomes [5, 6, 14, 15].

In many rural Ghanaian communities, few COVID-19 interventions have been tailored to their unique cultural and socio-demographic needs [4]. In rural Western Ghana, a not-for-profit organization (Cocoa360) was already in place, leveraging community engagement to address healthcare and educational access challenges. Cocoa360 was well-positioned to facilitate one of the rural responses to the COVID-19 pandemic [16, 17]. The organization rapidly developed and implemented a collaborative intervention called COVID-19 Preparedness and Outbreak Prevention Plan (CoCoPOPP) in the eight rural, remote communities it serves (Fig. 1). These communities’ unique rural and remote locations allow research on pandemic management and control, which can later be scaled to other rural areas. CoCoPOPP was designed to ensure that rural inhabitants are educated about COVID-19, and access PPE and high-quality healthcare services by eliminating treatment fees for respiratory tract infection cases at Cocoa360’s clinic.

Fig. 1
figure 1

Schematic of Cocoa360's COVID Preparedness and Outbreak Prevention Plan (CoCoPOPP)

Given the paucity of evidence on how public health interventions are designed in response to global pandemics, this paper employs document review and thematic analysis using the Promoting Action on Research Implementation in Health Services (PARIHS) framework. Our goal is to examine the extent to which CoCoPOPP’s design aligns with the components of the PARIHS framework. In this paper, we reviewed documents that informed CoCoPOPP’s design and used the PARIHS framework to thematically analyze the data we extracted. Such review and analysis are crucial for the future scaling of CoCoPOPP in rural communities with similar contexts. In addition, we share learnings from this process for development professionals in rural areas who seek to scale up participatory knowledge translation research and facilitate engagement at the community level.


Document review and the PARIHS framework

As a qualitative research method, document analysis can serve as an essential research tool either as a stand-alone or as part of a triangulation scheme [18]. It is mainly used as a stand-alone methodology when in-person approaches such as participant observations, interviews, and questionnaires are restricted by health and distance concerns [19]. Given the limitations in communication and travelling during the COVID-19 pandemic, the authors employed a methodology comprising both document review and thematic analysis using a public health framework. In addition to preventing health risks, document analysis proved a more suitable approach to circumvent potential challenges of distrust, hostility and retaliation toward researchers that typically happen during global pandemics [20,21,22]. Specifically, this study relied on Dalglish et al.’s approach to document review in health policy research: the READ methodology [23]. The READ approach comprises 1) Readying the materials under investigation, 2) Extracting data from the materials, 3) Analyzing the data, and 4) Distilling the findings from the data.

The Promoting Action on Research Implementation in Health Services (PARIHS) framework was employed for rigorous data analysis and distillation. PARIHS was developed to help professionals implement research into practice [24]. It structures the capture of evidence to use at the implementation level and considers its broader implementation context [25, 26]. At PARIHS’ the core are three key elements: level and nature of evidence, the context in which the research is to be applied, and facilitation of the implementation process [24]. With a strong emphasis on these three key elements, the framework provides essential guidelines for ensuring that interventions achieve the highest favourable outcomes with minimal unintended negative consequences when implemented. Several empirical studies corroborate the PARIHS framework’s strength by demonstrating that successful implementation is a function of evidence, context, and facilitation [24, 27,28,29,30,31]. The most successful implementation occurs when: the evidence is scientifically robust and matches professional consensus and target population needs (‘high’ evidence); the context is receptive to change with sympathetic cultures, strong leadership, and appropriate monitoring and feedback systems (‘high’ context); and there is appropriate facilitation of change with input from skilled external and internal facilitators (‘high’ facilitation) [24, 32].

Data collection and analysis

Combining the READ approach and the PARIHS framework analysis, this study rigorously reviewed and analyzed key documents that applied to developing the CoCoPOPP intervention as below.

Step 1: readying materials

Eleven documents related to CoCoPOPP’s development between 2019 and 2022 were obtained from Cocoa360’s staff, executives, research partners, and the internet. Records included the initial document outlining CoCoPOPP’s implementation plan, a logic model describing key inputs and outputs of the intervention, promotional materials such as brochures and videos, CoCoPOPP’s operational flowchart, donor, and partner update reports, as well as related press and articles on the internet. Document acquisition was greatly facilitated by Cocoa360’s executives and board members, who suggested additional documents such as grant reports, typically deemed confidential and inaccessible. All authors worked together to ensure that the final documents selected for the review adhered to Flick’s four yardsticks of document selection: authenticity, credibility, representativeness, and meaning [33].

Step 2: extracting the data

Data from the documents and internet-based searches were then extracted into a Microsoft Excel file, structuring the information according to the name/title, year of publication, source, aims and objectives of the document. Table 1 outlines the 11 documents that were reviewed and the key messages that were extracted.

Table 1 List of documents identified and analyzed

Step 3: analyzing the data

Relevant information from the extracted was organized according to the different components of the PARIHS framework. We specifically applied the evidence, context, and facilitation elements of the PARIHS framework in designing the CoCoPOPP intervention. These elements interact in robust and complex ways to influence CoCoPOPP’s implementation effectiveness. Two authors (SOF and MS) also conducted reflexive journaling to document how their pre-standing views and characteristics as Cocoa360 executives might have influenced the findings from the data analysis [34]. Finally, authors who are not Cocoa360 staff, including CB, EP, SA-D and YR, rated the CoCoPOPP intervention against the individual components of the PARIHS framework to minimize bias and improve rigour (Table 2).

Table 2 CoCoPOPP satisfying PARIHS framework elements and sub-elements

Step 4: distilling the findings

Using Dalglish et al.’s measures of data distillation, document analysis was determined to be wholly based on data saturation; the authors have read enough documents to be sufficiently confident about how Cocoa360 designed the CoCoPOPP intervention [23]. Data from framework analysis of the CoCoPOPP intervention was then distilled into the different components of the PARIHS framework, namely, evidence (research, professional experience, and community preference), context (culture, leadership, and evaluation), and facilitation (characteristics, role and style of the facilitators) (Table 3).

Table 3 Summary of how CoCoPOPP’s design aligned with the PARIHS Framework


Satisfying PARIHS’ evidence in the design of CoCoPOPP

CoCoPOPP’s design was evidence-informed because it relied on the research of published sources, matched professional opinion reached by the group, and met the needs of communities involved in the CoCoPOPP intervention. The design process considered the needs of the target communities because it depended on community perspectives and routine information derived from the members of the communities.

The design team also relied on the expert opinions and experiences of professionals. Physicians and clinical practitioners from the Ghana Health Service — Prestea-Huni Valley Municipal District (GHS-PHVMD), Tarkwa Breman Community Clinic (TBCC), and the Tarkwa Breman Community Health Planning Services (TBCHPS) — who understand the socio-cultural dynamics, disease prevalence, demographics, health care needs, and services utilization of the communities, were included. While the design team acknowledges the constraints of time and resources due to the COVID-19 pandemic, they also conducted an umbrella review of the literature regarding the design, implementation, and outcomes of previous pandemics such as the Ebola Virus Disease (Table 4).

Table 4 List of articles on pandemics reviewed for CoCoPOPP28

Satisfying PARIHS’ context in the design of CoCoPOPP

The design of CoCoPOPP matched the needs of the target population. The team considered the communities’ culture while acknowledging and including the participating rural communities’ leadership, monitoring, and feedback systems.

Culture context of CoCoPOPP

The intervention was designed to meet the cultural dynamics of the communities. As part of the planned implementation strategy, it was specified that:

CoCoPOPP will first be presented to the Chief and elders of Tarkwa Breman (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 [35].

This planned implementation strategy gave a more significant mandate to the Chief and elders (who are the community custodians) to approve 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 Village Committee (VC), we shall secure the necessary logistics [35].

Also, 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 in telling the community about CoCoPOPP and cultivating their support [35].

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 …; All participants recruited for the surveys and focus group discussion are treated as experts [35].

The study ensured that all participants were respected and treated as experts, reimbursed their travelling costs (if any), and received souvenirs (such as prepaid phone cards after interview /focus discussions). Instead of cash, gifts were provided to the participants considering their communities’ context and cultural norms. The plan also recognized potential acceptability, trust, recognition, and respect issues. It recommended ways to minimize retaliation by engaging the community leaders and VC in introducing CoCoPOPP to the communities. Furthermore, the recruitment announcement for CoCoPOPP’s research assistants was first delivered by local leaders at a community meeting. Similarly, community leaders were included in the discussions to promote community members’ participation.

CoCoPOPP’s design plan also included educating the population, promoting learning in the communities, and conducting research to collect data to try new and different techniques for organizational use. Further, the plan focused on sharing insights on epidemic management and control with the Ghanaian government and the wider global health and education community [see excerpts from the intervention document below].

The intervention presents a strong opportunity to research and gain insights on epidemic management and control with the Ghanaian government and the broader global health and education community. This will be crucial for controlling and managing future epidemics in similar settings [35].

The design team also noted that these implementation measures would increase CoCoPOPP’s likelihood of success in minimizing the spread of COVID-19 in the community while following the cultural dynamics of the local people.

Leadership context of CoCoPOPP

CoCoPOPP’s design outlined clear roles and objectives among the stakeholders involved in the intervention. It notes that stakeholders within each group must work together as a team and share power. For instance, TBCC healthcare workers worked closely with each other and had general authority in treating their clients. Each micro team, including clinical staff, and research assistants, 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 stakeholder and among the various team units (Table 5).

Table 5 Stakeholders involved in the implementation of CoCoPOPP

Evaluation of CoCoPOPP

Evaluation is one of the critical fulcrums CoCoPOPP’s design team leveraged. The intervention strategy allowed interdisciplinary investigators from Yale University, Vanderbilt University, University of Ghana, Ministry of Health (MoH), Ghana’s Health Service (GHS), and Cocoa360 to participate in monitoring and evaluation activities. Below is an excerpt from the implementation strategy, highlighting 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 [35].

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’s design also emphasized feedback on individuals, the team, and the intervention performance in the community.

Consistent with our community engagement principles as an organization, we will continue to update VC, community chiefs, and elders about progress → materials distributed; cases being seen [35].

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 [36]. 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. In contrast, the external facilitators were representatives from Yale University, Vanderbilt University, the University of Ghana, and MoH. These facilitators exhibited characteristics consistent with opinion leaders, change agents, champions, educational outreach workers, and linking agents in the implementation strategy to promote high facilitation.

With regards to community facilitation of CoCoPOPP, the Chief and elders were noted as 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 coordinate implementation synergy between Cocoa360 and members of the participating communities. Lastly, Cocoa360’s executives, TBCC healthcare workers, Cocoa360’s research team, social mobilizers, and data collectors were the internal change agents who promoted and ensured CoCoPOPP’s successful implementation. The internal change agents were chosen because they had strong interpersonal and communication skills, were knowledgeable and understanding, and earned the trust and respect of the community because of their consistent interaction with the community for at least 2 years. The external facilitators of CoCoPOPP were educational outreach workers and topic experts who were external to the intervention setting and knowledgeable about their area of specialization. They met with other facilitators to provide helpful information about the evidence-based intervention and feedback when necessary.

Role of the facilitators

These skilled facilitators had clearly defined roles to achieve a specific objective in CoCoPOPP’s implementation and ensure consistency in the delivery process. Facilitators, especially those who interacted with community members every day, had an experience of at least 2 years in the environment of the intervention area and were fully aware of the possible challenges they were likely to face. This would allow them to be flexible, show empathy when dealing with people, and be tenacious in overcoming challenges. Thus, CoCoPOPP’s design considered high facilitation of change with input from adept internal and external facilitators.


Our document review and thematic analysis using the PARIHS framework showed that CoCoPOPP’s design matched a pressing health need during the COVID-19 pandemic, considered the unique context of a rural Ghanaian setting, and was guided by robust and high-quality evidence from similar interventions in past outbreaks.

The findings reveal that CoCoPOPP’s design team prioritized the effective engagement of community leaders and members. Most importantly, they went beyond community leaders to local health workers and district-level government administrators. Such engagement efforts align with Kirsch et al.’s findings on the importance of effective community involvement during global pandemics [22].

Recognizing the importance of community engagement means they factored in the role of context in the success of intervention design, as many previous studies have shown. However, they failed to acknowledge community engagement’s potential unintended negative consequences. According to Attree et al., community engagement can lead to stress and burnout for some individuals who may lose time and financial resources during community engagement activities [37]. Such adverse effects on well-being are not accounted for in any of the CoCoPOPP documents we reviewed. Therefore, future efforts to replicate the CoCoPOPP intervention must account for this challenge of potential negative consequences during community engagement exercises.

Additionally, the CoCoPOPP documents demonstrated the critical role of research during the intervention design phase. The design team engaged scientists in fields such as public health, sociology, and medicine at Yale University, Vanderbilt University, and KNUST, Ghana, to assess the quality of evidence from existing literature using tools such as GRADE and GRADE-CERQUAL (Table 4). This cross-cultural partnership aligns with existing evidence on the importance of global north-south academic partnerships for achieving social innovations [38, 39]. While we commend CoCoPOPP’s design team’s efforts to leverage academic evidence from existing literature to inform the intervention’s design, we noted that no primary data was generated from prospective feasibility studies. While we recognize the challenges of time and resource constraints in the wake of the pandemic, we also note that evidence generated from a combination of primary and secondary data would further improve an intervention’s chances of success [40, 41].

Finally, results from the thematic analysis using the PARIHS framework show that CoCoPOPP’s design team comprised a wide range of credible experts and stakeholders. These included community leaders, Cocoa360’s staff and executives, and academic partners from institutions such as Yale University. Each design team member had their roles spelt out and possessed the credibility and authenticity to ensure that the most context-dependent, evidence-driven intervention was designed. The roles of facilitation also aligned with Rifkin et al.’s framework for participation which emphasized that facilitation is not an event but a process; CoCoPOPP’s facilitators were involved in all stages of the intervention, from design to implementation and maintenance [42].

Missing in the documents was the role of power and control during facilitation. Given the differing educational and financial backgrounds between facilitators and some community members, the influence of power during the intervention design cannot be ignored [43,44,45]. Also, it was unclear which part of the facilitation continuum the study design focused on; whether it was just for purely one-to-one activities or intended to continuously support the intervention from design through implementation and long-term sustainability. Clarity about the intervention’s facilitation continuum would be critical in maximizing the time, skills, and energy of facilitators such as community leaders and university professors, who are usually overburdened with other responsibilities [46].


A significant limitation of this study is the issue of selectivity bias. Bowen argues that the chosen documents for analysis are susceptible to selectivity bias given the influence data providers, in our case, Cocoa360’s executives, can have [18]. They can give information that only aligns with a particular positive narrative they want to communicate. Additionally, document analysis of an intervention’s design is not as straightforward as this analysis may suggest. Decisions may emerge during implementation that may elicit the revision of the original design plan, a significant challenge that our analysis might not have captured. Despite these potential biases, we think the findings are still robust given the extra efforts we put into member checking, peer-debriefing, and triangulation to enhance methodological rigour [47]. Therefore, we think this study is essential to the field of implementation science, particularly for intervention design analysis in Sub-Saharan Africa, where these types of studies are limited yet are very crucial during global pandemics such as Ebola and COVID-19.


CoCoPOPP’s design was consistent with the domains of the PARIHS framework since it involved the application of scientific evidence from past outbreaks, considered the unique rural context, and engaged the expertise of multiple facilitators in the community and academia. While many of the documents reviewed in this analysis indicate that Cocoa360 effectively engaged community leaders and members in CoCoPOPP’s design and implementation, it is still unclear how this would match up with primary data from interviews and questionnaires. Consequently, an important future step will be an assessment of the reach and fidelity of the CoCoPOPP intervention. Evidence from such studies will strengthen our findings from this document and framework analysis, solidifying the potential of scaling CoCoPOPP in rural communities in Ghana and beyond, particularly in other Sub-Saharan African countries with similar cultural settings.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to organizational confidentiality guidelines at Cocoa360, particularly, for donor and partner reports, but are available from the corresponding author on reasonable request. Links to publicly available data have been provided in Table 1.


  1. Hopkins J. Coronavirus resource center Johns Hopkins University COVID-19 tracker. 2021. Retrieved from Accessed 22 Mar 2021.

  2. Galal S. Coronavirus cases in Africa as of march 08, 2021, by country. 2021; Retrieved from Accessed 22 Mar 2021.

    Google Scholar 

  3. Ghana Health Service. COVID 19 update – Ghana. 2021; Retrieved from Accessed 22 Mar 2021.

    Google Scholar 

  4. Paintsil E. COVID-19 threatens health systems in sub-Saharan Africa: the eye of the crocodile. J Clin Investig. 2020; Retrieved from Accessed 22 Mar 2021.

  5. Anant Kumar K, Rajasekharan N, Shaffi FK. COVID-19: Challenges and its consequences for rural health care in India. Public Health Pract. 2020;(1) 10.1016/j.puhip.2020.100009.

  6. Jubayer F, Kayshar S, Islam LT. First COVID-19 case in the Rohingya camp in Bangladesh: needs proper attention. Public Health. 2020.

  7. Mba CJ. Population ageing in Ghana: research gaps and the way forward. J Aging Res. 2010;67:2157.

    Google Scholar 

  8. Mba CJ. Trends in the living arrangements of the elderly in Ghana: evidence from the DHS data, 1993–2003. In: Sahoo AK, et al., editors. sociology of ageing: a reader. New Delhi: Rawat Publications; 2009. p. 444–51.

    Google Scholar 

  9. Mba CJ. Population ageing in Ghana and correlates of support availability. Gerontechnology. 2007;6:102–11.

    Article  Google Scholar 

  10. Mba CJ. Population ageing and survival challenges in rural Ghana. J Soc Dev Afr. 2004;19:90–112.

    Google Scholar 

  11. Centers for Disease Prevention and Control. 2020; Accessed 10 July 2020.

  12. Amoah AG, Owusu SK, Adjei S. Diabetes in Ghana: a community based prevalence study in Greater Accra. Diabetes Res Clin Pract. 2002;56:197–205.

    Article  PubMed  Google Scholar 

  13. Ochu CL, Akande OW, Oyebanji O, et al. ‘Fighting a global war using a local strategy’: contextualism in COVID-19 response in Africa. BMJ Innov. 2021;7:347–55.

    Article  Google Scholar 

  14. Quaglio GL, Putoto G, Brant H, et al. COVID-19 in Africa: what is at stake? European parliamentary research service (EPRS). Eur Sci Media Hub (ESMH). Accessed 10 July 2020.

  15. Mitra S. The implications of COVID-19 for rural India. IDR. 2020;25 Scholar. Accessed 22 Mar 2021.

  16. Frimpong S, Russell A, Handy F. Re-imagining community development: the Cocoa360 model. In: Phillips R, Trevan E, Kraeger P, editors. Research handbook on community development. Cheltenham: Edward Elgar; 2020. p. 348–60.

    Chapter  Google Scholar 

  17. Frimpong S, Painstil E. A case for girl-child education to prevent and curb the impact of emerging infectious diseases epidemics. Yale J Biol Med. 2020;93:579–85.

    PubMed  PubMed Central  Google Scholar 

  18. Bowen GA. Document analysis as a qualitative research method. Qual Res J. 2009;9(2):27–40.

    Article  Google Scholar 

  19. Morgan H. Conducting a qualitative document analysis. Qual Rep. 2022;27(1):64–77

    Google Scholar 

  20. Ellard-Gray A, Jeffrey NK, Choubak M, Crann SE. Finding the hidden participant: solutions for recruiting hidden, hard-to-reach, and vulnerable populations. Int J Qual Methods. 2015;14(5):1–10.

    Article  Google Scholar 

  21. Goldstein DM. Qualitative research in dangerous places: becoming an “ethnographer” of violence and personal safety. Soc Sci Res Council. 2014.

  22. Kirsch TD, Moseson H, Massaquoi M, Nyeswah TG, Goodermote R, Rodriguez-Barraquer I, et al. Impact of interventions and the incidence of ebola virus disease in Liberia-implications for future epidemics. Health Policy Plan. 2017;32:205–14.

    Article  PubMed  Google Scholar 

  23. Dalglish SL, Khalid H, McMahon SA. Document analysis in health policy research: the READ approach. Health Policy Plan. 2020;35(10):1424–31.

    Article  PubMed Central  Google Scholar 

  24. Kitson AL, Harvey G, McCormack B. Enabling the implementation of evidence-based practice: a conceptual framework. Quality Health Care. 1998;7:149–58.

    Article  CAS  Google Scholar 

  25. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:1–13.

    Article  Google Scholar 

  26. Harvey G, Kitson A. PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2015;11:1–13.

    Article  Google Scholar 

  27. Kitson AL, Rycroft-Malone J, Harvey G, et al. Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges. Implement Sci. 2008;3:1.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Cummings GG, Estabrooks CA, Midodzi WK, et al. Influence of organizational characteristics and context on research utilization. Nurs Res. 2007;56:S24–39.

    Article  PubMed  Google Scholar 

  29. Estabrooks CA, Midodzi W, Cummings GG, et al. Predicting research use in nursing organizations. Nurs Res. 2007;56:7–23.

    Article  Google Scholar 

  30. Ellis TP, Schonauer MS, Dieckmann CL. CBT1 interacts genetically with CBP1 and the mitochondrially encoded cytochrome b gene and is required to stabilize the mature cytochrome b mRNA of Saccharomyces cerevisiae. Genetics. 2005;171:949–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Wallin L, Rudberg A, Gunningberg L. Staff experiences in implementing guidelines for kangaroo mother care - a qualitative study. Int J Nurs Stud. 2005;42:61–73.

    Article  PubMed  Google Scholar 

  32. Rycroft-Malone J, Kitson A, Harvey G. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care. 2002;11(2):174–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Flick U. An introduction to qualitative research. Sage. 2018.

  34. Watt D. On becoming a qualitative researcher: the value of reflexivity. Qual Rep. 2007;12(1):82–101.

    Article  Google Scholar 

  35. Cocoa360. Cocoa360's COVID Preparedness & Outbreak Prevention Plan. 2020.

    Google Scholar 

  36. Rycroft-Malone J, Seers K, Chandler J, et al. The role of evidence, context, and facilitation in an implementation trial: implications for the development of the PARIHS framework. Implement Sci. 2013;8:1–13.

    Article  Google Scholar 

  37. Attree P, French B, Milton B, Povall S, Whitehead M, Popay J. The experience of community engagement for individuals: a rapid review of evidence. Health Soc Care Community. 2011;19(3):250–60.

    Article  PubMed  Google Scholar 

  38. Eichbaum Q, Sam-Agudu NA, Kazembe A, Kiguli-Malwadde E, Khanyola J, Wasserheit JN, et al. Opportunities and challenges in north-south and south-south global health collaborations during the COVID-19 pandemic: the AFREhealth-CUGH experience (as reported at the CUGH 2021 satellite meeting). Ann Glob Health. 2021;87(1):90.

  39. Färnman R, Diwan V, Zwarenstein M, Atkins S, ARCADE consortium. Successes and challenges of north-south partnerships - key lessons from the African/Asian regional capacity development projects. Glob Health Action. 2016;9:30522.

    Article  PubMed  Google Scholar 

  40. Blackstone A. Social research: qualitative and quantitative methods: FlatWorld; 2019.

    Google Scholar 

  41. Merriam SB, Tisdell EJ. Qualitative research: a guide to design and implementation. 4th ed: Jossey Bass; 2016.

    Google Scholar 

  42. Rifkin SB, Muller F, Bichmann W. Primary health care: on measuring participation. Soc Sci Med. 1988;26:931–40.

    Article  CAS  PubMed  Google Scholar 

  43. Arnstein RS. A ladder of citizen participation. J Am Plan Assoc. 1969;35(4):216–24.

    Google Scholar 

  44. Cornwall A. Unpacking ‘participation’: models, meanings and practices. Oxford Univ Press Community Dev J. 2008.

  45. Pretty J. Participatory learning for sustainable agriculture. World Dev. 1995;23(8):1247–63.

    Article  Google Scholar 

  46. Harvey G, Loftus-Hills A, Rycroft-Malone J, Titchen A, Kitson A, McCormack B, et al. Getting evidence into practice: the role and function of facilitation. J Adv Nurs. 2002;37(6):577–88.

    Article  PubMed  Google Scholar 

  47. Maxwell JA. Qualitative research design: an interactive approach. 2nd ed. Thousand Oaks: Sage Publications; 2015.

    Google Scholar 

  48. Frimpong SO, Paintsil E. Community engagement in Ebola outbreaks in sub-Saharan Africa and implications for COVID-19 control: a systematic review; 2020.

    Google Scholar 

  49. Coltart CE, Lindsey B, Ghinai I, et al. The Ebola outbreak, 2013-2016: old lessons for new epidemics. Philos Trans R Soc Lond Ser B Biol Sci. 2017;372:1721.

    Article  Google Scholar 

  50. Cornish F, Priego-Hernandez J, Campbell C, et al. The impact of community mobilisation on HIV prevention in middle and low -income countries: a systematic review and critique. AIDS Behav. 2014;18:2110–34.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Salam RA, Haroon S, Ahmed HH, et al. Impact of community-based interventions on HIV knowledge, attitudes, and transmission. Infect Dis Poverty. 2014;3:26.

    Article  PubMed  PubMed Central  Google Scholar 

  52. McLean KE, Abramowitz SA, Ball JD, et al. Community-based reports of morbidity, mortality, and health-seeking behaviours in four Monrovia communities during the west African Ebola epidemic. Global Public Health. 2018;13:528–44.

    Article  PubMed  Google Scholar 

  53. Abramowitz SA, McLean KE, McKune S, et al. Community-centered responses to Ebola in urban Liberia: the view from below. PLoS Negl Trop Dis. 2015;9:e0003706.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Abramowitz SA, McKune M, Fallah J, et al. The opposite of denial: social learning at the onset of the Ebola emergency in Liberia. J Health Commun. 2017;22:59–65.

    Article  PubMed  Google Scholar 

  55. Sambala EZ, Ndwandwe DE, Imaan LM, et al. Evaluation of influenza surveillance systems in sub-Saharan Africa: a systematic review protocol. BMJ Open. 2019;9:e023335.

    Article  PubMed  PubMed Central  Google Scholar 

  56. WHO Ebola Response Team. Ebola virus disease: World Health Organization; 2018.

    Google Scholar 

Download references


We gratefully acknowledge the thoughtful comments we received on earlier drafts from Priya Bhirgoo, Julian Addo, and Irma Lee. Thanks also to Newlove Gershon Nkegbe for the valuable discussion of the ideas presented in this paper. We thank Francis Arthur-Holmes (Partner, Evidence and Advocacy, Cocoa360, and Director of Yale-Cocoa360 Partnership) for the formatting, his comments and helping with the revision of the manuscript for publication. In addition, the insightful depth reflected in comments provided by Cocoa360 team members also considerably strengthened the manuscript.


This study was not funded by any agency.

Author information

Authors and Affiliations



SOF conceptualized the idea and wrote the first complete draft. MS and SKH edited the original draft and prepared the final submission. SD-A and KT-S reviewed the original draft and made substantive contributions. YR, EP and CB edited and reviewed the final draft and made substantive contributions. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Shadrack Osei Frimpong.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Sharon Dorcoo-Attipoe (SD-A), Elijah Paintsil (EP), Kristina Talbert-Slagle (KT-S), Carol Brayne (CB), and Yusuf Ransome (YR) declare that they have no competing interests. Shadrack Osei Frimpong (SOF), Moro Seidu (MS), and Sam Kris Hilton (KH) are executives and staff members of Cocoa360.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Frimpong, S.O., Seidu, M., Hilton, S.K. et al. Development of a community-based COVID-19 intervention in rural Ghana: a document analysis. BMC Public Health 22, 1920 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI:


  • COVID-19
  • Cocoa360; CoCoPOPP
  • Rural Ghana