Eliminating onchocerciasis within the Meme River Basin of Cameroon: A social-ecological approach to understanding everyday realities and health systems

Abstract

Background Onchocerciasis affects some of the world’s most marginalized people, perpetuating poverty and inequalities. Mass Drug Administration (MDA) with Ivermectin has taken place within the Meme River basin region in Cameroon for over 15 years. Despite this, onchocerciasis is still prevalent in the region due to existing and emerging contextual challenges. Using a social-ecological approach we explore the everyday realities of communities, highlighting the challenges and potential solutions that could support Neglected Tropical Disease (NTD) programmes when transitioning from control to elimination of onchocerciasis in this highly endemic area and other similar communities. Methodology/Principal finding In-depth interviews (71) with community members and Community Drug Distributors (CDDs) were conducted to understand current knowledge, attitudes, and behaviours in relation to transmission, prevention and treatment of onchocerciasis. Through application of the social-ecological model, four key themes were identified: 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social determinants (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental determinants (exposure, housing, occupation and poverty); and 4. health seeking pathways and decision making for treatment (access, cost and preferable treatment routes). We discuss these core and cross cutting themes (gender differences and community participation/ownership) in relation to intersectoral collaboration, gender equity and health systems support, making recommendations for NTD programmes within the context of integrated and interdisciplinary approaches. These include the need for; intersectional and gender analysis at the local level, addressing environmental dimensions of onchocerciasis through integrated and regular health promotion, vector control strategies and access to safe water sources; reflection and action that embeds responses to social and economic barriers to MDA; integrated case detection and management that is responsive to onchocerciasis symptoms and related stigma and a fair and just support network for CDDs. Conclusion/Significance NTD programmes need to respond to diverse community circumstances and behaviours. Communities are not a homogeneous risk group and treating them in this way will delay elimination. A deeper understanding of individual needs and their capacity to seek prevention and treatment must be considered if onchocerciasis is to be eliminated and the remaining impacts managed.

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“…The provision of literacy level-appropriate health information by community health workers also enabled vaccination uptake [ 40 ]. Sociocultural facilitators to community volunteer motivations included wanting to help their own communities [ 63 , 71 ], or receiving assistance with farm work [ 71 ]. From a gender perspective, men were less likely to attend training to be community mobilizers in immunization campaigns [ 27 ], and male community distributors of ivermectin were less likely to access female community members due to either the head of the household needing to be present but unavailable at the time, or women seeking alternative treatments [ 60 , 63 ].…”

“…This included community volunteers involved in immunization campaigns in Malawi [ 27 ], Somalia [ 34 ], and Bangladesh [ 57 ], and community distributors of onchocerciasis treatments in the Democratic Republic of Congo [ 33 ], and Cameroon [ 37 , 61 ]. Lack of remuneration or resources for community distributors led to low involvement [ 33 ], poor attrition, dissatisfaction [ 61 ], and recruitment [ 63 , 64 ]. As community distributors were often living in poverty, in some cases, donations for ivermectin treatment were requested which decreased uptake [ 60 , 63 ].…”

“…Lack of remuneration or resources for community distributors led to low involvement [ 33 ], poor attrition, dissatisfaction [ 61 ], and recruitment [ 63 , 64 ]. As community distributors were often living in poverty, in some cases, donations for ivermectin treatment were requested which decreased uptake [ 60 , 63 ]. Conversely in India ‘Anganwadi workers’ in a measles immunization campaign [ 54 ], enabled more time to be dedicated to the intervention when remunerated, facilitating campaign success.…”

“…Similarly, once treatments had been acquired, failure to engage community members on appropriate timing of mass distribution limited intervention uptake [ 32 , 37 , 60 , 61 , 63 , 64 , 68 ]. In several studies community volunteers reported many potential participants were not home to receive treatment due to farming [ 32 , 63 , 64 , 68 ]. Other issues related to intervention timing included varying and multiple campaigns in the same communities, which caused intervention fatigue and confusion leading to disengagement in measles-rubella vaccination [ 27 , 49 ] and mass administration of ivermectin for onchocerciasis [ 60 , 61 ].…”

“…Several ivermectin distribution interventions reported the perceived need of treatment by the community had impacted uptake [ 32 , 60 , 67 ], with some community members citing preference for traditional medicines as more effective for onchocerciasis [ 63 ]. In immunization [ 26 , 40 , 58 ] and mass drug administration campaigns for onchocerciasis [ 32 , 33 , 37 ], the availability and training of community members (often as ‘volunteers’) in implementation was central to uptake.…”