An approach to integrate population mobility patterns and sociocultural factors in communicable disease preparedness and response

Human movement shapes the geospatial spread of communicable diseases, with patterns influenced by health status, distance, duration and purpose of travel, infrastructure, economic systems, and sociocultural connectivity. Cross-border mobility further complicates detection and response because neighboring countries have differing public health capacities and systems. While contact tracing and travel history investigations are critical immediately following an event, they are labor-intensive, rely on recall, and do not provide a broader view of where transmission could occur if contacts or locations are missed. Quantitative methods (e.g., mobile phone data, modeling, surveys, satellite imagery, phylogenetics) effectively quantify aspects of mobility and risk but do not explain the social drivers—the who and why—of movement. Social network analysis offers insights into relationships and transmission dynamics, yet there is a gap between such analyses and decision-making in applied public health. In this context, the Togo and Benin Ministries of Health sought to better understand regional mobility and sociocultural connectivity related to Lassa fever spread. The study presents the Population Connectivity Across Borders (PopCAB) toolkit, a flexible, rapidly deployable approach to characterize mobility and apply findings to preparedness and response, and describes its application to inform cross-border strategies for Lassa fever in Togo and Benin.

The paper situates PopCAB within existing approaches: (1) Case-based strategies such as contact tracing and travel history investigations are effective for immediate response but are resource-intensive and limited in scope for broader risk assessment. (2) Quantitative analyses using call detail records, mobile location data, mathematical models, censuses and surveys, satellite imagery, and phylogenetics quantify spatiotemporal transmission dynamics and exposure/import/export risk but often lack insight into sociocultural drivers of movement. (3) Social network analysis elucidates relationships and dependencies influencing movement and disease spread, providing richer understanding of social-spatial factors, yet translation into rapid, applied public health decision-making remains limited. The authors identify a methodological gap: accessible, rapid, community-engaged tools for applied settings to characterize who moves, why, and how, to complement sophisticated analytics and inform operational decisions.

PopCAB is a mixed-methods, four-phase approach designed to integrate mobility into public health practice. - Team and roles: A leadership group (defines objectives, adapts tools, ensures outputs meet objectives), field implementers (conduct events), a data manager, and a GIS analyst (map design, spatial data creation/management). Stakeholders from traditional and non-traditional sectors are engaged via key informant interviews (KIIs) and focus group discussions (FGDs), both incorporating participatory mapping; optional site-specific quantitative surveys can be added. Phase 1: Prepare - Define context-specific objectives (e.g., characterize seasonal migration among specific groups; assess healthcare-seeking along routes during an outbreak). - Desk review of existing information and spatial data; develop an implementation plan and timeline; list key informants and stakeholder groups; identify priority geographic areas; adapt toolkit materials (languages, probes); design base maps appropriate to scale (national, regional, community) with essential reference features (settlements, roads, rivers, boundaries, key facilities). Prefer large-format printed maps (36×48 in) or stitched smaller prints; hand-drawn maps are acceptable if printing is not feasible. - Outputs: Objectives and plan; lists of areas and stakeholders; adapted tools and base maps. Phase 2: Characterize - KIIs/FGDs with participatory mapping: Field teams (facilitator + two note-takers) guide discussions using adapted question guides covering WHO travels, WHY, WHERE from/to, HOW (transport), DURATION, and identification of high-priority public health areas. Each FGD participant receives a numeric ID; map annotations receive alphabetical IDs to link notes and spatial features. Discussions can be audio-recorded for quality control. Facilitators orient participants to maps and ensure inclusive engagement; each event uses a fresh base map. Post-event, teams review notes and maps to ensure accurate linkage of text and spatial information. - Site-specific structured surveys (optional): Conducted by survey teams at prioritized locations (e.g., markets, health facilities, transport hubs) identified from KIIs/FGDs, during times capturing relevant periodicity, with sampling tailored to objectives. Data include modes/purposes/duration/origins/destinations. Without rigorous sampling, results are not generalizable but can indicate magnitude and spread potential. - Data management: Qualitative analysis of notes; creation of a location database for all mentioned points and routes; GIS geocoding of points and routes using annotated maps and existing datasets or GPS. Integration of qualitative, spatial, and quantitative databases; analyses and narrative reports; determination of need for additional events. - Outputs: Databases (qualitative, spatial, quantitative), lists of follow-up areas and groups, narrative report(s). Phase 3: Visualize - Creation of static/interactive maps with points (places of interest) and lines (routes), thematically characterized (built environment, cultural identities, healthcare-seeking, economic systems), with optional seasonality and narratives. Effective visualization supports translation into action. Phase 4: Apply - Translate results into tailored preparedness/response action plans: e.g., schedule refresher training before expected migration surges; allocate resources to strengthen surveillance in at-risk locations; target culturally connected secondary communities; refine cross-border information sharing and coordination. Decide on additional data collection as needed. - Outputs: Community/national/multinational action plans, tailored preparedness plans integrating mobility-informed risk assessments. Application in Togo and Benin - Round 1 (March 2017): Binational, national-level PopCAB integrated into a multisectoral meeting during a Lassa response. Stakeholders included MOH leaders, police, immigration, mayors, environmental health, clinicians. National base maps for Togo and Benin were prepared; materials translated to French with context-specific probes. FGDs with participatory mapping and binational synthesis identified overlapping movement pathways and filters by movement reasons (e.g., health care, economic, agricultural). Outputs highlighted a seasonal circular migration across northern Togo, Benin, and Nigeria and associated cross-border healthcare-seeking. Leadership selected high-connectivity areas for enhanced collaboration and facilities along pathways for additional training, and prioritized northern areas for deeper fieldwork. - Round 2 (April 2018): Objectives: characterize (a) cross-border circular migration between northern Togo/Benin and western Nigeria and (b) traditional and formal healthcare-seeking along routes. Stakeholders: surveillance officers, border officials, migrants, healthcare professionals, traditional healers, transporters. Priority areas: 10 urban centers across Kara and Savanes (Togo) and Atakora, Donga, Borgou (Benin). Nine field teams (4 Togo, 5 Benin) formed. Training: two 4-day workshops (Kara; Parakou) comprising method training, 1 day of field FGDs, and debrief. Implementation: 54 MOH staff conducted 21 FGDs in 14 cities with 224 participants from six stakeholder groups. Data processing produced databases of 167 points of interest and 176 routes. Visualization layered multi-stakeholder results, retained multiple descriptors for the same locations (e.g., market, town, traditional healer site), and enabled thematic queries (e.g., origins of visitors to traditional healers in western Benin). Application: strategies refined for cross-border collaboration, procedures to engage neighbors during outbreaks, selection of facilities for enhanced training based on connectivity, and approaches to integrate traditional healers into surveillance and education. The PopCAB toolkit was refined and integrated into national and district preparedness plans. Rapid application occurred during a December 2018 Lassa case in Borgou, Benin, enabling faster cross-border coordination and improved travel history documentation and visualization.

- PopCAB can be rapidly deployed and adapted to characterize community connectivity relevant to communicable disease spread and to inform operational decisions. - Round 1 (2017) identified a seasonal circular migration pathway across northern Togo, Benin, and Nigeria with overlapping cross-border healthcare-seeking patterns, guiding selection of high-connectivity areas and health facilities for enhanced collaboration and training. - Round 2 (2018) implementation metrics: 54 MOH staff trained; 21 FGDs conducted in 14 cities over eight days; 224 participants across six stakeholder groups; 167 points of interest and 176 routes identified and geocoded. - Visualization products enabled filtering by drivers (e.g., healthcare, agriculture, economic) and integration of multi-stakeholder perspectives for the same locations. - Application outcomes: refined cross-border information sharing and collaboration; clarified outbreak engagement procedures with neighboring countries; prioritized health facilities for training based on connectivity to migration routes; identified ways to integrate traditional healers into surveillance and community education; PopCAB incorporated into national and district preparedness plans. - During a December 2018 Lassa case in Benin, prior PopCAB results facilitated rapid, coordinated multinational response and enhanced travel history data collection and visualization.

The findings demonstrate that integrating community-engaged qualitative and spatial data on mobility and sociocultural connectivity into public health practice improves the ability of ministries of health to anticipate and respond to cross-border disease transmission risks. PopCAB filled a practical gap between sophisticated analytics and on-the-ground decision-making by capturing who moves, why, where, and how, and translating this knowledge into targeted preparedness and response actions. In regions with high cross-border movement, such as West Africa, this approach supported enhanced surveillance, health education, contact tracing in culturally connected communities, and cross-border coordination. The experience in Togo and Benin, and corroborative use cases (e.g., Uganda’s Ebola preparedness), indicate that PopCAB-derived insights can be operationalized to mitigate international spread and strengthen global health security.

This paper presents PopCAB, a flexible, rapidly deployable toolkit that integrates participatory mapping and stakeholder engagement to characterize population mobility and sociocultural factors relevant to communicable disease preparedness and response. Its application in Togo and Benin produced actionable insights—documented points and routes of connectivity, identification of high-risk areas and facilities, and strategies to engage traditional healers—leading to refined cross-border collaboration and integration into preparedness plans. The approach complements quantitative and network-based methods by providing context-rich, decision-ready information. Broader adoption by ministries of health, as seen in Uganda, suggests PopCAB can help countries better anticipate and manage cross-border disease threats and support International Health Regulations implementation.

- Without clearly defined objectives and skilled facilitation, KIIs/FGDs may yield superficial, scattered information across many locations/routes, limiting actionable guidance for resource allocation; thorough preparatory desk reviews and adequate training can mitigate this. - Analyses and interpretations depend on the geographic and stakeholder coverage of data collection; summaries should always be presented alongside where, and with whom, PopCAB events occurred to avoid overgeneralization. - PopCAB results are not social network analyses and do not quantify strength of associations between places or groups; they are intended to complement, not replace, rigorous network analyses. - Robust spatial databases and maps require a qualified GIS analyst and appropriate software to accurately geocode and manage annotated locations and routes. - Optional site-specific surveys without rigorous sampling are not generalizable, though they can illustrate magnitude and spread potential.