Do Communities Really "Direct" in Community-Directed Interventions? A Qualitative Assessment of Beneficiaries' Perceptions at 20 Years of Community Directed Treatment with Ivermectin in Cameroon.

Recent studies in Cameroon after 20 years of implementation of the Community Directed Treatment with ivermectin (CDTI) strategy, revealed mixed results as regards community ownership. This brings into question the feasibility of Community Directed Interventions (CDI) in the country. We carried out qualitative surveys in 3 health districts of Cameroon, consisting of 11 individual interviews and 10 Focus Group Discussions (FGDs) with specific community members. The main topic discussed during individual interviews and FGDs was about community participation in health. We found an implementation gap in CDTI between the process theory in the 3 health districts. Despite this gap, community eagerness for health information and massive personal and financial adhesion to interventions that were perceived important, were indicators of CDI feasibility. The concept of CDI is culturally feasible in rural and semi-urban settlements, but many challenges hinder its actual implementation. In the view of community participation as a process rather than an intervention, these challenges include real dialogue with communities as partners, dialogue and advocacy with operational level health staff, and macroeconomic and political reforms in health, finance and other associated sectors.

Barriers to the National Onchocerciasis Control Programme at operational level in Cameroon: a qualitative assessment of stakeholders' views.

BACKGROUND: The global burden of onchocerciasis is the heaviest in sub-Saharan Africa. Studies have shown the importance of the role of Community-Directed Distributors (CDDs) and nurses in onchocerciasis control, but little is known about their experience in implementing onchocerciasis control programmes. Our aim was to document the barriers that CDDs and local health administrators face in implementing onchocerciasis control activities. METHODS: We conducted a qualitative survey consisting of 16 in-depth interviews and 8 focus group discussions (FGDs) across three health districts of Cameroon. We interviewed a total of 9 local health officials at the district and Health Area levels, and 7 CDDs. Eight FGDs were conducted with CDDs and Health Committee members. RESULTS: The major barriers to the implementation of Community Directed Treatment with Ivermectin that we identified were linked and interrelated. Examples of these barriers included: contextual factors (geographical and cultural background), top-to-bottom planning, insufficient human and material resources, and lack of transparency in the management of the programme's funds. CONCLUSIONS: The CDTI at operational level still faces many obstacles which negatively affect therapeutic coverages. This can lead to the non-adhesion of the communities to the programme, consequently jeopardizing the sustainability of the onchocerciasis elimination programme. We recommend that the national programme planners put in place a transparent management and planning system for onchocerciasis elimination activities, with better communication with local programme stakeholders.

Audit of the community-directed treatment with ivermectin (CDTI) for onchocerciasis and factors associated with adherence in three regions of Cameroon.

BACKGROUND: After more than 15 years of community-directed treatment with ivermectin (CDTI) in the Centre 1, Littoral 2 and West CDTI projects in Cameroon, the epidemiological evaluation conducted in 2011 revealed that onchocerciasis endemicity was still high in some communities. To investigate the potential reasons explaining this high endemicity, a cluster coverage survey was conducted in April-May 2015 in three health districts (HD), to assess the implementation of the CDTI, the 2014 therapeutic coverage and the five-year adherence to treatment. A two-stage cluster design was considered during analyses, with data weighted proportionally to age and gender distribution in the population. RESULTS: In the three HDs, 69 community leaders, 762 heads of households, 83 community drug distributors (CDD) and 2942 household members were interviewed. The CDTI organization and the involvement of heads of households were in average weak, with 84.0% (95% CI: 81.2-86.4%) of them who had not participated in activities during the 2014 mass drug administration (MDA). On average, six of ten community leaders declared that the period of treatment was decided by the health personnel while the CDDs selection was made during a community meeting for only 43.4% of them. The 2014 weighted therapeutic coverage was 64.1% (95% CI: 56.8-70.9%), with no significant difference in the three HDs. The survey coverages were lower than the reported coverages with a significant difference varying from 14.1% to 22.0%. Among those aged 10 years and above, 57.8% (95% CI: 50.2-65.1%) declared having taken the treatment each time during the last five MDAs with no significant difference among HDs, while 9.8% (95% CI: 7.5-12.8%) declared that they had never taken the drug. In multivariate analysis, the most important factors associated with the five-year adherence to treatment were high involvement in CDTI and age (40+ years). CONCLUSIONS: Despite more than 15 years of CDTI, there was still weak community participation and ownership, a lower coverage than reported and an average five-year adherence in the surveyed HDs. The reinforcement of the community ownership by the Ministry of Public Health officials and the timely procurement of ivermectin as requested by the communities are some measures that should be implemented to improve the therapeutic coverage, adherence to treatment and hence achieve onchocerciasis elimination. Further anthropological and entomological studies would provide better insights into our understanding of the persistence of the disease in these three CDTI projects.

Important progress towards elimination of onchocerciasis in the West Region of Cameroon.

BACKGROUND: After more than a decade of community-directed treatment with ivermectin (CDTI) in the West Region of Cameroon, epidemiological evaluation conducted in 2011 showed that onchocerciasis endemicity was still high in some communities. The conceptual framework for onchocerciasis elimination recommends in such case, to conduct additional phase 1A surveys at intervals of three to four years. Therefore, to assess the progress made towards the elimination of onchocerciasis in the West CDTI projects, we conducted a cross-sectional survey in May 2015 in 15 unevaluated communities where the highest baseline endemicity level were found in 1996. All volunteers living for at least five years in the community, aged five years or more, underwent clinical and parasitological examinations. Individual adherence to ivermectin treatment was also assessed. Analyses of data were weighted proportionally to age and gender distribution in the population. RESULTS: The mean age was 28.4 ± 22.2 years and there were 55% of women among the 2058 individuals examined. The weighted prevalences were 5.5%, 2.1% and 1.7% for microfilaridermia, nodule and cutaneous signs, respectively. The weighted microfilaridermia prevalences varied from 4.0 in 5-9 years old to 11.6% in 40-49 years old. In the 30 children under 10 years examined in Makouopsap, the weighted prevalences were 49.9% for microfilaridermia and 13.3% for nodule. In surveyed communities, the weighted prevalences varied from 0 to 41.6% for microfilaridermia, with 11 (73.3%) communities having <5%. Except Makouopsap which had 41.6%, all the surveyed communities were below 15% for microfilaridermia prevalence. The community microfilarial load (CMFL) expressed in microfilariae/skin snip (mf/ss), also significantly dropped by 98-100%, from 3.75-33.16 mf/ss in 1996 to 0-0.94 mf/ss in 2015. The weighted therapeutic coverage in 2014 was 69.4% and the 5 years' adherence was only 39.3% among participants. CONCLUSIONS: After more than 15 years of CDTI, there is an important progress towards the elimination of onchocerciasis in the communities surveyed. Innovative strategy like semi-annual ivermectin treatment plus vector control or the adjunction of a vector control strategy to the current annual treatment should be implemented in the bordering districts of the Centre and West Regions, as well as in other parts of the country with persistent high prevalences in the sight of onchocerciasis elimination.

Adherence to ivermectin is more associated with perceptions of community directed treatment with ivermectin organization than with onchocerciasis beliefs.

BACKGROUND: The fight against onchocerciasis in Africa has boomed thanks to the Community Directed Treatment with Ivermectin (CDTI) program. However, in Cameroon, after more than 15 years of mass treatment, onchocerciasis prevalence is still above the non-transmission threshold. This study aimed to explore a possible association between people's beliefs/perceptions of onchocerciasis and of CDTI program, and their adherence to ivermectin in three regions of Cameroon. METHODOLOGY/PRINCIPAL FINDINGS: A cross sectional survey was carried out in three health districts with persistent high onchocerciasis prevalence. Participants were randomly selected in 30 clusters per district. Adherence to ivermectin was comparable between Bafang and Bafia (55.0% and 48.8%, respectively, p>0.05) and lower in Yabassi (40.7%). Among all factors related to program perceptions and disease representations that were studied, perceptions of the program are the ones that were most determinant in adherence to ivermectin. People who had a "not positive" opinion of ivermectin distribution campaigns were less compliant than those who had a positive opinion about the campaigns (40% vs 55% in Bafang, and 48% vs 62% in Bafia, p<0.01), as well as those who had a negative appreciation of community drug distributors' commitment (22% vs 53% in Bafang, 33% vs 59% in Bafia, 27% vs 47% in Yabassi; p<0.01). The most common misconception about onchocerciasis transmission was the lack of hygiene, especially in Bafia and Yabassi. In Bafang, high proportions of people believed that onchocerciasis was due to high consumption of sugar (31% vs less than 5% in Bafia and Yabassi, p<0.001). CONCLUSION/SIGNIFICANCE: There are still frequent misconceptions about onchocerciasis transmission in Cameroon. Perceptions of ivermectin distribution campaigns are more strongly associated to adherence. In addition to education/sensitisation on onchocerciasis during the implementation of the CDTI program, local health authorities should strive to better involve communities and more encourage community distributors' work.

Still mesoendemic onchocerciasis in two Cameroonian community-directed treatment with ivermectin projects despite more than 15 years of mass treatment.

BACKGROUND: After more than a decade of community-directed treatment with ivermectin (CDTI) in Centre and Littoral Regions of Cameroon, onchocerciasis endemicity was still high in some communities according to the 2011 epidemiological evaluations. Some corrective measures were undertaken to improve the CDTI process and therefore reduce the burden of the disease. The objective of the present study was to assess the progress made towards the elimination of onchocerciasis in the Centre 1 and Littoral 2 CDTI projects where the worst performances were found in 2011. To this end, a cross-sectional survey was conducted in April 2015 in eight communities in two health districts (HD), Bafia in Centre 1 and Yabassi in Littoral 2, chosen because assessed at baseline and in 2011. All volunteers living for at least five years in the community, aged five years or more, underwent clinical and parasitological examinations. Individual compliance to ivermectin treatment was also assessed. Analyses of data were weighted proportionally to age and gender distribution in the population. RESULTS: In the Bafia and Yabassi HD, 514 and 242 individuals were examined with a mean age of 35.1 (standard deviation, SD: 20.7) and 44.6 (SD: 16.3) years, respectively. In the Bafia HD, the weighted prevalences varied from 24.4 to 57.0 % for microfilaridermia and from 3.6 to 37.4 % for nodule presence across the surveyed communities. The community microfilarial load (CMFL), expressed in microfilariae/skin snip (mf/ss), significantly dropped from 20.84-114.50 mf/ss in 1991 to 0.31-1.62 mf/ss in 2015 in all the surveyed communities. In the Yabassi HD, the weighted prevalences varied from 12.3 to 59.3 % for microfilaridermia and from 1.5 to 3.7 % for nodule presence across the surveyed communities, while a significant drop was observed in CMFL, from 20.40-28.50 mf/ss in 1999 to 0.48-1.74 mf/ss in 2015. The 2014 weighted therapeutic coverage of participants varied from 65.8 % (95 % CI: 58.4-73.2) in Yabassi HD, to 68.0 % (95 % CI: 63.3-72.7) in Bafia HD, with important variations among communities. CONCLUSIONS: After more than 15 years of CDTI, onchocerciasis is still mesoendemic in the surveyed communities. Further studies targeting therapeutic coverage, socio-anthropological considerations of CDTI implementation and entomological studies would bring more insights to the persistence of the disease as observed in the present study.