Analyses

We compared the approaches that teams used to design and implement PopCAB. We compared, by country and PopCAB phase, details about the implementation timelines, team compositions, project goals, priority geographic areas or population groups of interest, data collection strategies, analytic approaches, and the application of results. To consolidate information for the comparative analysis, we gathered qualitative, quantitative, and spatial data from project implementation materials and outputs and qualitative data from discussions with the teams. Here, we intend to present a broad overview of PopCAB results from each country, rather than specific details.

Preparation Phase

The national MOH port health director (in Tanzania and DRC) or border health focal point (in Uganda) led the PopCAB teams; their overall goal was to gather information about cross-border movement and community connectivity to inform border health strategies (Tables 2,3,4). Each team also included an International Health Regulations (2005) (1) national focal point; MOH national-level port health staff; district-level port health staff where available; government staff with epidemiology, public health surveillance, or emergency operations expertise; and Field Epidemiology Training Program or Field Epidemiology Laboratory Training Program residents. Government leadership for Uganda included the director and deputy director of the National Institute of Public Health. In Tanzania, MOH staff in collaboration with CDC conducted all activities. In DRC and Uganda, the governments led portions of activities independently; the remaining activities were conducted in collaboration with CDC and Africa Field Epidemiology Network; in Uganda, Baylor Uganda, Infectious Diseases Institute, and Rakai Health Sciences Program also supported activities.

Figure 2

Figure 2. Timeline of Population Connectivity Across Borders implementation across Democratic Republic of the Congo (DRC), Tanzania, and Uganda during the COVID-19 response, May 2020–March 2022.

The teams implemented their PopCAB activities over 2 years of the COVID-19 response (Figure 2). DRC leveraged previously scheduled staff training, site visits, and cross-border meetings to implement events. In contrast, Uganda and Tanzania implemented PopCAB-focused initiatives to conduct many FGDs and KIIs in a short time. For example, Uganda implemented 30 events in Ntungamo, Isingiro, and Masaka districts near the Tanzania border in May 2020 after a disproportionate increase in COVID-19 cases in the region. Tanzania implemented 24 events in Arusha, Pwani, and Tanga Provinces in July 2020, recognizing the need to adapt COVID-19 response measures for continued cross-border movement and travel. Throughout the pandemic, the DRC border health director incorporated PopCAB events, or orientation to PopCAB, into all cross-border meetings the program joined or hosted. The DRC, Tanzania, and Uganda MOHs shared this accomplishment during bilateral meetings in Uganda with DRC in September 2021 and in Tanzania with DRC in March 2022 (Figures 1, 2).

Across these events, the teams in all 3 countries implemented PopCAB to address a few consistent objectives. One focused on a priority to adapt strategies for surveillance and risk communication at POEs and POCs to limit the spread of COVID-19 across international and domestic administrative boundaries. A second aimed to enhance public health benefit and judicious use of resources for surveillance and community outreach by identifying and prioritizing specific geographic areas visited by cross-border travelers. A third consistent objective was to prioritize secondary travel routes and areas of interest for mobile populations, including formal and informal POEs, health facilities, and community areas, for enhanced staff training and surveillance. The teams also implemented PopCAB to inform cross-border collaboration. Unique objectives included understanding the influence of COVID-19 lockdown measures on cross-border population movement in Uganda and addressing human activity associated with livestock husbandry in Tanzania.

Characterization Phase

All teams implemented PopCAB events at national and community levels in administrative areas along international borders and in their countries’ large urban areas, e.g., Kinshasa, Dar es Salaam, and Kasese. DRC and Uganda also implemented events specifically at POEs; DRC implemented all their community-level events at POEs.

The teams invited various stakeholders to participate in PopCAB events, including security officers, truck drivers, traditional healers, village health volunteers, sex workers, and pastoralists (Table 1). These groups represented not only communities that may move across borders but also those that interact with travelers. Tanzania and Uganda implemented events with persons representing a variety of occupations and responsibilities relevant to a broader geographic scale, such as a district or region. Only Uganda implemented KIIs to gather more information from leadership or to address challenges with gathering multiple representatives for a group of interest, such as traditional healers, security personnel, and medical staff.

Visualization Phase

The countries’ teams developed narratives and reports that listed all the LOIs and routes. The reports also described themes from the informal qualitative analyses completed by those who directly conducted the discussions or recorded notes. For example, these reports provided details about cross-border travel patterns to seek care from traditional healers, travel routes community members took when seeking healthcare to conceal residence status, or routes to avoid lockdown policies. The teams included photos of the annotated base maps and photos of participants during the events.

Each team followed a different approach to managing and analyzing the gathered information. The DRC team completed detailed reports rapidly, within 1 week, after each PopCAB event; however, they did not develop qualitative or spatial datasets of LOIs or routes for future visualizations and analyses. They took this approach because they intended to focus on applying results immediately after the discussions and their staff availability to process and manage the data over time was limited.

The Tanzania team developed detailed FGD transcripts after each event to facilitate their ability to integrate and analyze results across multiple PopCAB activities. They also developed, in collaboration with CDC, summary tables listing all annotated LOIs. The Tanzania team worked closely with CDC team members on qualitative data analysis, use of geographic information systems, and cartography to learn new skills in analyzing the qualitative data and geocoding the LOIs. These dedicated data management and analysis efforts led to detailed, formal spatial datasets of the LOIs and routes and initial qualitative thematic analyses. Although a compiled report from each event or group of events took longer to create, the team could use those results to develop improved visualizations for already-defined and future program goals.

The Uganda team focused on developing detailed FGD and KII transcripts after each event, along with detailed summary tables of all mentioned and annotated LOIs and travel routes. This process was supported by dedicated team members who had expertise in qualitative and spatial data management. The team analyzed the qualitative data for themes about reasons and routes for movement. The spatial analysts and cartographers geocoded the results, building robust spatial datasets of >1,000 unique LOIs and routes. The team also combined the results with other data-gathering initiatives completed by partners on the team, including Infectious Diseases Institute and Baylor Uganda, to characterize cross-border healthcare-seeking behaviors.

The data management approaches of Tanzania and Uganda led to the ability to develop more broadly effective reports and presentations. They were able to include visualizations to address various MOH objectives identified during the preparation phase or newly identified during pandemic response initiatives.

Application Phase

All teams used PopCAB results to adapt national, district, and POE-level policies, programs, and resource allocation plans (Table 5). All teams enacted these adjustments using qualitative and spatial information mentioned during the PopCAB events. Despite the different strategies implemented in the visualization phase, all teams continued to use the results from completed events throughout the pandemic. The Tanzania and Uganda teams completed multiple analyses to respond to established and newly identified goals throughout the response, stemming from the approaches they followed to develop robust datasets with the gathered data.

The teams implemented various contextually-specific initiatives using the results to address consistent and unique objectives. The DRC MOH used PopCAB results from FGDs in and around Kinshasa to identify 3 urban locations for new mobile COVID-19 surveillance to increase the ability to detect illness at key traveler congregation points. In addition, the DRC MOH maintained a plan to routinely conduct PopCAB in Kinshasa to guide when and where to adjust the locations of those mobile urban surveillance sites. They also rapidly applied results to extend operating hours for certain POEs to accommodate unique movement patterns identified through the FGDs.

The Tanzania Port Health unit identified areas for increased engagement with village committees and security authorities to strengthen border health surveillance. As part of that effort, they identified community health workers in areas with increased cross-border connectivity in Dar es Salaam and Tanga Provinces and provided them with additional training on event-based surveillance. The MOH also used the data to select high-traffic locations where they enhanced community outreach and installed handwashing stations.

District-level officials in Uganda on the Tanzania border worked with owners of nighttime bars visited by persons from across the border to increase COVID-19 surveillance. The Uganda team also identified mobile phone market vendors that serve cross-border communities to support them in distributing COVID-19 risk communication materials to high-priority population groups. Along that border and the western border with DRC, the Uganda team applied results to identify schools and markets preferred by cross-border communities for enhanced risk communication in preparation for and during the COVID-19 response lockdown. Like Tanzania, Uganda also applied results to identify village health volunteers who worked in areas with increased cross-border connectivity, including those along routes used by persons fleeing conflict from DRC into Uganda, for prioritized refresher training on community-based surveillance.

All of the teams applied the results from the binational PopCAB events during cross-border meetings to prioritize official and unofficial POEs and other LOIs along travel routes across their shared borders for enhanced risk communication and traveler surveillance. They also prioritized groups of contiguous administrative areas in cross-border surveillance zones for more robust and sustained collaboration and information sharing.