Exploring Existing Malaria Services and the Feasibility of Implementing Community Engagement Approaches amongst Conflict-affected Communities in Cameroon: A Qualitative Study

"[T]he community dialogue approach could be an effective tool to remove some of the barriers including raising awareness of CHWs [community health workers] and the training they receive and building trust between community members and CHWs."

Cameroon is one of the countries with the highest burden of malaria. Since 2018, there has been an ongoing conflict in the country, which has reduced access to healthcare for populations in affected regions, especially internally displaced people (IDPs). In response, the Ministry of Health in Cameroon has been implementing a strategy aiming to ensure that by 2025, 60% of populations living more than 5 kilometres from a health facility have access to high-quality healthcare services through multi-purpose community health workers (CHWs). The strategy also aims to increase demand for community health services through communication and community dialogue structures. This qualitative study was conducted as part of a larger research study to understand the challenges IDPs face when accessing malaria services, factors that influence their use of CHWs, and assess the preference of key stakeholders for different community engagement interventions to improve uptake of malaria prevention measures and services.

Between May and July 2021, the researchers carried out 29 focus group discussions (FGDs) and 11 in-depth interviews (IDIs) in two regions of Cameroon, Southwest (SW) and Littoral. FGDs were held with CHWs and community members, and semi-structured IDIs were conducted with regional government staff, council staff, community leaders, and community-based organisations. The data were analysed thematically.

The study confirmed that access to healthcare has become increasingly challenging in conflict-affected areas. Although the Ministry of Health is providing CHWs to improve access, several barriers remain that limit uptake of these services, including: lack of awareness of CHWs' existence or the services they provide; availability (e.g., due to lack of transportation for CHWs), cost of malaria drugs sold by CHWs, language barriers, limited supply of testing and treatment, perceived (low) quality of care; and distrust related to perception of CHWs' motivation, their links to government, associations with COVID-19 vaccine promotion, local relationships, and doubts about their training and competency.

When asked about existing community engagement practices, a few CHWs described door-to-door campaigns to raise awareness of malaria: In Muyuka, community members reported that health communication activities are normally delivered by the town crier or CHWs, who gather community members together to provide health education and to carry out community clean-up campaigns. Community members in Muyuka also described CHWs conducting door-to-door household education sessions on how to use insecticide-treated nets. Similarly, in Kumba, CHWs reported carrying out awareness-raising activities using a community dialogue approach. In Ekondo-Titi, community leaders reported that ward leaders are normally responsible for gathering the community together for health talks. However, many participants reported that, since the start of the conflict, some of these community engagement activities had ceased.

In general, FGD participants responded positively to the proposal of community engagement approaches. Community members and CHWs felt community-centred approaches would help to engage everyone and overcome current challenges with community participation. CHWs, community members, and regional-level stakeholders mentioned several factors that could limit the success of community-based approaches, including a lack of participation from the community if incentives could not be provided or if travel was affected by adverse weather or security concerns. There was also concern raised over potential disagreements in meetings, difficulties with power dynamics, a lack of a meeting venue, and language barriers, particularly concerning the preferred use of non-local languages. A member of a community-based organisation also said that said engagement with the community leader prior to the introduction of new methods was important for an approach to be successful.

In terms of specific community engagement approaches:

• Community dialogues: Community members, CHWs, and the participating community-based organisation responded positively to this idea. Respondents said community dialogues would give everyone the opportunity to be involved and were more likely to reflect the expectations of the community when compared with village health committees. However, community members also reported that the provision of treatment would also be needed, as education alone will not help anyone who contracts malaria.
• Scorecards: Respondents responded positively to the idea of these participatory tools to collect feedback from community members and felt they could gather everyone's views, help to identify individual weaknesses, and capture the thoughts of community members who do not like to speak up in other forums. However, some were concerned that this approach may not be inclusive for members of the community who are visually impaired or where there are language or literacy barriers.
• Village health committees: Community members in Manjo felt this approach would be useful for raising awareness, organising environmental management activities, and discussing sanctions for those who do not follow environmental management practices. In Ekondo-Titi, Kumba and N'lohe, and Kolla, respondents felt village health committees would provide a forum for everyone to participate, mobilise resources, and enhance adherence to the decisions made. Among the challenges: the need for support to set up these committees, the sustainability of the approach if committee members were unpaid, other organisations taking advantage of the training provided and employing its members, the need to include health professionals in the committee, the importance of gender balance among the committee members, and the potential emergence of tensions between communities and CHWs.

As reported here, the use of the community scorecard approach and village health committee could also be implemented in conjunction with the community dialogue approach to overcome challenges such as trust in CHWs and to improve the quality of services they provide by monitoring training and adherence to guidance.

The findings from this study have led to a recommendation to review support given to CHWs. The results have been used to design a project using three key interventions to enhance the quality of malaria prevention and control services: an adapted community dialogue approach (the Community Health Participatory Approach), improved support for CHWs, and vouchers to cover the cost of transport to and treatment from a CHW or health facility. This project is currently being implemented in 80 communities in SW and Littoral regions.

In conclusion: "Communities in conflict-affected regions of Cameroon continue to have limited access to healthcare services, in part due to poor use of CHW services provided. Community engagement approaches can be an effective way to improve the awareness and use of CHWs. However, these approaches alone will not be sufficient to resolve all the challenges faced by conflict-affected communities when accessing health and malaria services. Additional interventions are needed to increase the availability of CHWs, improve the supply of diagnostic tests and treatments and to reduce the cost of treatment for all."

Full list of authors, with institutional affiliations: Margaret Ebob Besem E.O., Malaria Consortium and University of Buea; Elisabeth G. Chestnutt, Malaria Consortium; Laura Donovan, Malaria Consortium; Ann‑Sophie Stratil, Malaria Consortium; Helen Counihan, Malaria Consortium; Claude Ngwayu Nkfusai, Malaria Consortium and University of Kwa‑Zulu Natal; Helen Hawkings, Malaria Consortium; Blanka Homolova, Malaria Consortium; Kolawole Maxwell, Malaria Consortium Nigeria; Kevin Baker, Malaria Consortium and Karolinksa Institute; Yakouba Zoungrana, Malaria Consortium Nigeria; Elvis Asangbeng Tanue, University of Buea and Reach Out Cameroon (REO); Glennise Ayuk, REO; Noukeme Bibiche Modjenpa, REO; Alain Metuge, REO; Isabelle Nganmou, Konmofamba Actions Sans Frontieres (KASAFRO); Dorothy Achu, Ministry of Public Health, Yaoundé, Cameroon; Samuel Wanji, University of Buea and Research Foundation in Tropical Diseases and Environment; Elizabeth Berryman, Malaria Consortium; and Lundi‑Anne Omam, University of Cambridge and REO