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.

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.