The role of community co-designed interventions for malaria prevention and control in conflict-affected communities in Cameroon’s Southwest and littoral regions

Abstract

Background

In 2022, Cameroon was ranked the 11th of the 11 high-burden countries responsible for 70% of the global malaria burden largely due to sustained conflict in the Southwest and Northwest regions since 2018. From May 2021 to April 2024, a mixed-methods study was conducted of three community-based, co-created interventions, a community dialogue approach called the Community Health Participatory Approach (CoHPA), community health workers (CHWs) supportive supervision, and health vouchers for treatment and transportation. The study involved formative, intervention and endline phases; the qualitative findings from the endline evaluation are presented here.

Methods

A qualitative study of 189 host, displaced and returnee participants, involving nineteen focus group discussions (FGDs) with CHWs and separate female and male community groups, and, eighteen in-depth interviews (IDIs), with local councillors, community leaders, supervisors, district, and facility chiefs were conducted. The study compared perceptions of knowledge and attitudes to care-seeking, information and communication channels, community leadership roles and malaria service capacity and quality and care pathway functionality with formative research results. It further evaluated perceptions of the intervention process regarding fidelity, dose, adaptations, process, mediators, reach and recommendations. Data were analysed thematically using NVivo 14.

Results

Communities perceived increased knowledge of malaria prevention and control, with challenges where insecurity reduced facility-based services. Participants described increased participation in community and household prevention activities. CHWs valued supervision. CHW and supervisor support to CoPHA increased trust in CHW services, reducing use of roadside drug sellers. Vouchers increased treatment access, timely referrals, although unsubsidized co-morbidities caused payment challenges. Community leaders questioned voucher sustainability.

Conclusion

Interventions were perceived to have improved prevention and health-seeking awareness and behaviours, community health service utilization and treatment access. Participants felt empowered to create and evaluate solutions.

Background

Cameroon bears the 11th highest burden of malaria in sub-Saharan Africa. Malaria prevention and control are particularly challenging in conflict-affected communities[1]. In 2017, the Northwest and Southwest regions of Cameroon descended into a violent armed confrontation between state military and non-state armed groups, stalling progress in malaria management. Since then, widespread human rights violations including kidnapping, killing and torture of civilians have been recorded. This has led to recurrent cycles of displacement, with civilians seeking refuge in forests, farmlands, rural, urban and peri-urban areas in the Southwest, Northwest, and Littoral region of Cameroon, and in neighbouring Nigeria [2]. The Office for Coordination of Humanitarian Affairs (OCHA) estimated that the crisis displaced over 670,000 people by 2020, rising to 831,138 by 2022 [2, 3]. The crisis also caused the destruction of health facilities and loss of health personnel and across the Southwest and Northwest regions. 37% of health facilities became non-functional. Consequently, the availability of data on malaria morbidity from the Northwest and Southwest regions was, and continues to be, severely limited [4].

When the programme was conceived in 2018, there were 6.2 million cases and 11,192 deaths from malaria nationally [4]. In 2021 this had risen to 6.459 million cases and 12,587 deaths [4–6]. The 2018 National Demographic Health Survey (DHS) found that, malaria prevalence was 10% in the SW region of Cameroon, and that 60% of all interactions with the health system were due to malaria [7]. In addition, only 46% of households were estimated to have access to an insecticide-treated net, though this is thought to be lower, as only urban areas were assessed due to high levels of insecurity [7]. Malaria treatment within Cameroon was variable, with only 21% of children aged 6–59 months with fever receiving a rapid diagnostic test and 21% receiving artemisinin-based combination therapy [7].

A significant proportion of internally displaced people (IDPs) in the Southwest had spent periods of time in remote forests and farmlands where they had no access to basic healthcare, including malaria prevention and treatment services. Of the assessed villages 60% reported a displaced population with limited access to health care facilities, 25% were more than 60 min from the closest health facility by foot. In addition, 65% of key informants cited distance as the primary challenge to accessing health care, followed by 17% who indicated that services were too expensive [8]. Community-based management of malaria by community health workers (CHWs) has been the main resource used by the National Malaria Control Programme (NMCP) and humanitarian partners to reach IDPs with high-quality malaria services [9]. Community acceptance and community-based delivery are key elements in the fight against malaria [10].

This paper details the qualitative endline findings of the research study ‘Breaking Barriers in Access to Effective Malaria Treatment amongst Conflict-Affected Communities of the Southwest and Littoral Regions of Cameroon’ (Breaking Barriers) funded by Expertise France. The study examined the effect the crisis has had on access and quality of malaria services. The study objective was to provide evidence to inform policy on the provision of high-quality malaria care and treatment for internally displaced populations (IDPs) and contribute to improved malaria programming in conflict- affected communities. The research was carried out in three phases: formative research phase (baseline), intervention phase and endline. Results from the formative phase (baseline study) are published [5, 6]. The intervention phase ran from May 2022 to April 2024 and included the implementation of three co-designed, innovative community-based interventions namely, the Community Health Participatory Approach (CoHPA), supportive supervision for CHWs, and health vouchers for subsidized malaria care and transportation for severe cases. CoHPA involved monthly community-led dialogues addressing key malaria topics, while supportive supervision provided monthly mentoring for CHWs to improve performance and trust. Vouchers subsidized treatment costs and transport for internally displaced pregnant women and children under five years, offering greater access to services [11].

The final phase of the research involved an endline study, conducted in May 2024, to evaluate participants’ experiences after the intervention delivery. This included both a quantitative and qualitative evaluation. This manuscript presents the qualitative findings from the endline study, highlighting the potential impact of community-driven approaches to improve access to malaria services in vulnerable settings. Findings from the quantitative endline evaluation will be published separately. The qualitative endline aimed at understanding participant’s satisfaction with the co-created interventions—and reflections on the impact of the three interventions, and their sustainability and recommendations.

Methods

Study design

The study was conducted in 80 communities across five study sites, four in the SW and one in Littoral region, focusing on displaced populations, returnees and host populations in insecure, hard-to-reach areas. The formative phase explored changes in people’s experience of malaria as a disease of concern and their ability to prevent and control of malaria in their communities following the implementation of three community co-designed interventions. Participants were asked to select between three community engagement interventions: community dialogues, community scorecard systems and village health clubs or committees [6, 10–12]. Communities were supportive of the Community Dialogue Approach and community scorecards with interventions to increase CHW capacity and reduce treatment costs. A co-creation workshop with key stakeholders followed to finalize the details of the community-based interventions, The Community Dialogue Approach which was redefined and named as Community Health Participatory Approach (CoHPA) to avoid confusion with a different Cameroonian intervention with the same name; support to CHW supportive supervision and vouchers for subsidized care for simple and severe malaria and transport for referrals. The 24-month implementation phase of the research studied the process and impact of the three selected interventions. Five district field supervisors supervised activities.

Community volunteers, one male and one female per community were selected by their community, trained and supervised to facilitate CoHPA meetings. A manual and flipbook were developed to support the programme. The meeting content, involved a  series of seven facilitated dialogues, six with specific topic guides and activities following the manual and using the flipbook, and agreed action plans by the community using the knowledge gained and the seventh to consolidate and review the programme. Each meeting included a review of the last action plan, questions and comments and joint completion of CoHPA score card; the scorecard involved reviewing volunteer knowledge and skills, relevance of topic, how easy the topic was to follow, quality of time and venue, and, level of participation. Participants then agreed on date and place of the next CoHPA dialogue.

An assessment of CHW supervision capacity was undertaken followed by CHW supervisor training and support. The existing CHW and supervisor training materials were reinforced with a manual and competency score card and refresher training and ongoing monitoring were supported. REO ensured the availability of malaria supplies through advocacy to the NMCP. Vouchers were provided to CHWs, and agreements made with local transport providers and district hospitals to accept vouchers and to be reimbursed for treatment on submission of invoices for services. A process evaluation was conducted to monitor activities and make required adaptations. The qualitative component of the endline study involved conducting focus group discussions (FGDs) and in-depth interviews (IDIs) in the 80 high-malaria-studied communities. Topic guides were used to explore participants’ experiences and knowledge on the co-created community-based interventions and explore their knowledge and practices in seeking malaria services during the intervention. Participants were purposefully sampled in all project communities to participate in the study data collection for the endline which took place in June 2024.

The community groups were selected from IDPs, returnees and host communities in both regions:

• i.Women who play a key role in health issues management and information-seeking about family health in general including mothers of young children as the most at-risk group from clinical and severe malaria.
• ii.Men, some of whom are heads of households and have a decision-making role related to health seeking for household members.
• iii.People living with disability who face challenges to reach health services.

Key informant interviews were conducted with selected health professionals and community leaders.

Setting

This study was conducted in 64 communities in the  conflict-affected Southwest region and in 16 communities in four districts in Littoral region which hosts a high number of IDPs. The study was conducted in 16 communities, in each selected district the Southwest region – Ekondo-Titi, Kumba, Muyuka and Tombel – and four in each district in Littoral region, which were areas selected for the formative research. There was paucity of data on service availability in Ekondo-Titi, Kumba, Muyuka and Tombel as conflict-affected study sites due to the conflict [14]. Four districts were chosen in Littoral, Manjo, Melong, Mbanga, and Nkongsamba, Manjo replaced Penja district, studied in the formative research, due to insecurity.

Data collection

FGD guides with community members, CHWs, and IDIs explored the impact of the Breaking Barriers programme on malaria in their communities, focusing on malaria as a disease of concern. The interviews gathered insights into participants’ knowledge and experience of accessing health services and their perceptions of the intervention, providing context and meaning to the concurrent quantitative KAP component of the endline study. The qualitative endline study used the same interview guides as the baseline and mid-term review as the basis for the interview guides to enable comparison. Interview guides were developed and informed by project documents on the main evaluation themes, tailored for different participant groups. FGDs and IDIs were led by field supervisors who had worked on the programme. The field supervisors undertook a two-day training which included conducting FGDs and IDIs, open-ended questions, facilitating groups, projective techniques, and managing data collection tools. Standard procedures for conducting FGDs and IDIs were followed, including obtaining informed consent, choosing an appropriate time and place for interviews, and ensuring appropriate group sizes and language use. Interviews were conducted in houses provided by community leaders and community organizations and in district supervisor offices. Interviews took an average of one hour. FGDs and IDIs were conducted in the local language, and audio recordings were made using tape recorders. Quality control during fieldwork included daily spot checks by supervisors, reviews of audio recordings and end-of-day debrief meetings with the research team and supervisors, either face-to-face or by phone, to discuss challenges and prepare for the following day.

Data management and analysis

All IDIs for the Southwest were conducted and transcribed in English. All FGDs for Ekondo Titi, Tombel, Kumba and Muyuka were conducted in English or pidgin English and transcribed in English. Non-English transcripts were translated into English. All transcriptions and translations from the Southwest were completed by field supervisors. In Littoral, FGDs and IDIs were recorded and conducted and transcribed in French. The French transcripts were then translated into English by a member of KASAFRO staff who knew the project well and was fluent in both languages. All transcripts across the two regions were reviewed before analysis, to ensure clarity of language and grammar.

Three members of the research team conducted the data analysis. Data were analysed using NVivo version 14.0 using thematic analysis. Each research team member reviewed at least two FGDs and two IDI transcripts for each of the project sites, to become familiar with the content. A coding framework was developed based on emerging themes and codes through inductive and deductive approaches. The same codes were used in the formative research and the endline but with additional codes to capture participants’ experience and evaluation of the three interventions including whether they believed they had selected the right community engagement intervention. Codes were also created for participants’ thoughts on sustainability and recommendations for the programme. Transcripts were coded by the research team. The code framework was used to apply consistency in coding systems among researchers, allowing for flexibility, through comments, notes or additional codes based on data content. Following coding, researchers each developed preliminary emerging themes, these were discussed and a common list of themes agreed. Themes and sub-themes were further consolidated across the different versions developed by researchers, checking for repetition of content in themes and sub-themes and re-formulating accordingly. De-identification was completed ensuring anonymity.

Ethical and regulatory considerations

Ethical approval was sought and obtained from the Institutional Review Board of the Faculty of Health Sciences of the University of Buea, IRB00008917. Administrative authorization was obtained from the Southwest Regional Delegation of Public Health and the District Health Services in all study sites. Written and verbal informed consent was sought from all study participants.

Results

A total of 19 FGDs were conducted across the study sites, six with men from the communities and eight with women from the communities and five with CHWs. A total of 24 women and 26 men from the communities participated in the FGDs; a total of 40 CHWs participated in the FGDs (Table 1), the gender of CHWs was not recorded. Each FGD had 8–12 participants.

Table 1.

Number of participants and FGDs held with community members and by study site

Study Sites	Community Participants		CHWs
	Men	Women
Ekondo Titi	9 (1)	9 (1)	27 (3)
Tombel	9 (1)	15 (2)	31 (4)
Kumba	8 (1)	7 (1)	23 (3)
Muyuka	9 (1)	18 (2)	35 (4)
Littoral	14 (2)	14 (2)	34 (5)
Total	49 (6)	63 (8)	123 (19)

A total of 18 structured in-depth interviews (IDIs) were conducted with supervisors of CHW and services and with CHWs, local councillors and community leaders. Across the study sites 11 men and seven women participated in IDIs (Table 2).

Table 2.

Number of in-depth interviews conducted by study site

Study site	Number of participants
	Men	Women
Ekondo Titi	4	0
Tombel	2	2
Kumba	1	2
Muyuka	2	1
Littoral	2	2
Total	11	7

IDIs interviews held with managers of CHW and services, and CHWs, local councilors and community leaders (Table 3).

Table 3.

In-depth Interviews

	District
Stakeholder category	Ekondo Titi	Tombel	Kumba	Muyuka	Littoral
Health services stakeholders
District clinical supervising officer	1	1	1	1	1
Chief of clinic	1	1	1	1	1
Community stakeholders
Community leader	1	1	1	1	1
Counsellor	1	1			1

Results from the FGDs and IDIs reveal participant perceptions on the impact of the project and their beliefs and attitudes towards malaria and related healthcare activities. The three community interventions were designed to improve CHW service utilization.

Four main themes emerged:

• 1. The perceptions on the impact of the Breaking Barriers project on malaria as a major health concern;

• 2. The impact on malaria healthcare-seeking behaviours;

• 3. Participants’ experience of each of the interventions;

• 4. Perceptions of the sustainability of CoHPA, supportive supervision and voucher systems; each intervention included recommendations.

Theme 1: Perception of the impact of Breaking Barriers project on malaria as a major health concern

Participants reported that malaria was a frequent health concern. Environmental factors, mortality rate, and financial burden emerged from the analysis as major health concerns.

Environmental factors

Overall, the Breaking Barriers project was appreciated for its contribution to community health improvements. Participants described how the environment had improved.

“The project helped us a lot because when the CSA [agent de santé communitaire] sensitized us, we didn’t take it seriously, but when the project came with the CoHPA, everyone participated, together we made decisions to solve our problems by cleaning up all the places where mosquitoes are present. And with the CoHPA, a lot of behaviour has changed’—male community member, Littoral

Participants described how they had experienced a reduction of malaria cases including CHWs who had been involved in the baseline prevalence study and of malaria deaths and related these to improvements in the environment.

“There was really a change because by the first time where we went out to do the test, we had a lot of malaria at that time you know by then the crisis too was so, it was so hard, in the way that most villages and camp were very, very dirty. The second time we went out for the malaria test again, we, we have, we saw that, we saw that at least we have reduced, and er we had about er, about er 60%, maybe, by the end of this, at the endline survey maybe there will be more improvement.”—male CHW, Tombel

The rainy season, with many households experiencing multiple cases of the disease. Malaria was reported as a constant threat to the community, with families regularly seeking treatment for the disease.

“The most dangerous disease for now in our community is malaria, so I think the services is ok for the purpose for which it has been designated. Because if we succeed in eradicating Malaria, we will get our children stronger. Most times our children get to miss out on school because of malaria which causes them to vomit, have fevers, and be weak, so if we can keep that in check then I think we will be ok. Malaria is one of the most recurrent illnesses around and if it is well taken care of, then I think our community will be safe”—male community leader, Myuka

Communities also described the challenge of maintaining clean environments and preventing mosquitoes related in the face of persistent environmental challenges particularly stagnant water and poor drainage. Two key challenges were the community environment and commercial company waste management issues and associated advocacy needs.

“Malaria is a very very big problem in my community, because my community is bounded by forest so even if community member keeps their surrounding clean and do other works mosquito will still leave from the forest and meet them in the community. There is stagnant water even after sensitization to avoid stagnant waters, during days where the community is supposed to keep the village clean, they go out and still see standing water’—CHW, Kumba

“We have a big cocoa farm especially in one quarter where I reside and it surrounds those living there, the owner has been asked to sell the farm, but he refuses, and that place is a dumping ground for people’s dirt”—male CHW, Kumba

Participants still cited that malaria was a major health concern but the project had increased awareness of malaria and encouraged improved environmental management.

‘When we are keeping our environments clean, our toilets and backyards clean, it makes the malaria to reduce. But the disadvantages, at first, we never knew. We were keeping our houses dirty and they were not neat inside but since our hygiene and sanitation now has been taught, at least the malaria has reduced and it’s not too much again’—female community member. Tombel

“Malaria is not affecting us as much, we have the knowledge, keep our compound clean our environment clean, how to care for our children, not just ourselves…You can go six months before getting malaria, it wasn’t like that before. There is a big change”—female community member, Littoral

Across all sites, health promotion was described as key to fostering early treatment-seeking behaviour and improving health outcomes, but sustained resourcing of the required associated actions was required.

Mortality rate

Participants reported that malaria-related mortality was a recurrent concern across all the project sites, particularly among vulnerable groups such as children under five years of age, pregnant women and the elderly.

“For me malaria is a very big problem in my community, because I realized that even though the people go to the hospital and receive treatment for malaria, after one month they still fall ill of malaria. So, it has made malaria to be a big problem in my community”—CHW, Ekondo Titi

Participants had experienced a fall in mortality during the project study.

“So, many children in my community now, at least the rate of malaria has really dropped. So, we thank Reach Out and death rate too has reduced”—male community member, Kumba

In Ekondo Titi, CHWs reported that malaria accounts for about 80% of their consultations. Participants also emphasized that malaria affected people of all ages but was especially dangerous for children under five and pregnant women.

“Most families here have had to deal with malaria at some point, and it’s particularly dangerous for our children and pregnant women”—female community member, Muyuka

Across all sites, participants agreed that malaria is a major public health issue, particularly for those who have been displaced, and requires sustained resources, health education, and preventive efforts to manage it.

“More than half of that population tells you why [malaria] is a serious burden in this particular catchment area, secondly we may want to look at it by protocol or by norms and standards that the positivity rate is high but when we look at it in another hand we realize that this area that you are seeing like this where we are 99% of the population are migrating from the red zone because of the crises and on daily basis we are having influx of persons migrating”—female Chief of Clinic, Kumba

In Muyuka, women’s groups highlighted the high number of deaths, particularly during the peak malaria season. In Ekondo Titi, Littoral and Kumba, CHWs and community leaders reported several cases of malaria-related deaths, and mentioned delays in accessing care were a primary contributing factor. Financial difficulties and inadequate healthcare infrastructure were reported as major barriers to timely treatment.

“Why we consider malaria as problematic is because it is deadlier. When you look at the statistics in Cameroon, malaria has a high mortality rate, more than any other illness. Looking at these statistics, we realize that there is high infant mortality, followed the mortality of pregnant women and regular adults in the cause of their daily activities die from malaria more than many other diseases”—female community member, Muyuka

“In my community, there are parents who are poor, who can’t send their children to school. And when the child gets sick, he’s overwhelmed…As they hang out, the child dies. So, that’s why we created this programme. This programme has helped parents in our community”—CHW, Littoral

Financial burden of malaria

Participants across all project sites reported that malaria puts a strain on the family’s financial income. They described how the cost of treatment affects their families’ welfare as the inability to pay for treatment results in delayed healthcare-seeking. In particular, low-income families supporting displaced community members struggled to cover transportation costs for treatment. Participants described recurrent cases of malaria within the same household increasing financial hardship, which in turn affected their ability to meet other basic needs. Participants appreciated free or subsidized health services to minimize this financial burden.

“A family finds themselves doing everything on the other side and finds themselves here with children without pay, with nothing to support them. That’s how we found many people, more than six people, in a house because they are called to do that, not just the six people who are members of a family. And that means that when they are sick, they don’t even have enough to eat”—male District Centre de Sante Officer, Littoral

Most community members, CHWs and key informants reported that people are now more proactive in seeking care and treatment for malaria. However, in the most conflict-affected communities, some families still delayed seeking formal care due to fear of travelling during times of conflict, with participants opting to manage symptoms at home for as long as possible.

“This CoHPA session allowed many people to avoid even going to buy medicines on the side of the road…Many came to be tested when it was positive…When it was a bit complicated, I refer…When I gave vouchers, they were very happy. It has had a positive impact in my community…It took a lot of awareness to convince them, especially the internally displaced people who live in precarious conditions. And these IDPs as well as the destitute people who were a priority are really grateful”—CHW, Kumba

“We’ve been educating people about the importance of coming to the clinic early, and it’s helped a lot, but some still wait too long.”—CHW, Muyuka

However, the inconsistent availability of drugs often leads to delays in treatment. Across all project sites, participants reported that while malaria care was generally available, there were times when health facilities ran out of key supplies. Across all sites, participants agreed that improving the consistent availability of malaria treatment and diagnostic tools was critical for ensuring timely care.

“Sometimes the health centres run out of malaria drugs, and we have to wait or go elsewhere for treatment, which makes the situation worse”—CHW, Tombel

“At times like that, most of the time they come to me for drugs. So, I always make sure they have drugs in their community. I always make sure when I am in Buea, I always try to request”—male Chief of Clinic, Ekondo Titi

Theme 2: Perception of the impact of Breaking Barriers project on malaria healthcare-seeking behaviours;

Participants perception on health care seeking behaviours were categorized in to awareness of the CHW roles and services in the community, the perceived quality of care by CHWs and how the project improved utilization of health services, by improving their availability and affordability.

Awareness of the CHW roles and services in the community

Although challenges remain, most participants stated that the Breaking Barriers project overall has improved health seeking behaviour. CoHPA meetings and CHW services were reported to have a positive impact on health-seeking behaviour. CoHPA meetings helped to raise the profile of CHWs.

It has also helped to bring, let’s say, to bring the community and the community workers and even the notables together”—female community member, Kumba

Awareness of the CHW roles and services in the community

Participants noted that health promotion had improved families’ understanding of the importance of early treatment-seeking and adhering to malaria prevention practices, communities understand how to use CHW services.

‘I can say before maybe they don’t know the activities of the community workers. But thanks to the CoHPA meeting and thanks to the BBs initiative, at least they now know what the community workers have to offer. And they now know what reach out is offering them’—female DCSO Kumba.

‘And now, giving the health voucher was aimed at treating severe malaria in children under 5 in hospitals. So, it was just enough that, after awareness in the community, when the member of the community who has the sick child approaches the ASC, the ASR, we will give him access to the ASC. It really brought relief to a lot of families.—female DCSO Littoral.

The perceived quality of care

Participants emphasized the success of community-based approaches, such as home visits by CHWs and CoHPA meetings, in raising health awareness and encouraging behavioural change. These methods allowed for personalized health advice and empowered families to take proactive steps in disease prevention. Community members appreciated the immediate support provided by CHWs, which helped families understand how to prevent malaria and access care.

‘And I think so because at a certain moment, what you mostly find with CHWS is her treatment for malaria, that they are treated a lot of cases of malaria’—male DCSO Tombel.

‘The majority go to a community health worker first, before hospital. Because they know the benefits they get if they pass through them first. And also, there is no community health worker the people will not like to consult with. They love and make use of all their services. also, I haven’t witnessed any case of biased treated against anyone. They are all treated equally….’—male Myuka Community Leader

Participants across all sites agreed that support to the community-based and outreach-focused approaches of the Breaking Barriers project were key to its success.

“The home visits by the CHWs are really helpful because they give us advice specific to our families, and we feel more comfortable asking questions.”—female community members, Muyuka

CHWs follow through on referrals which assists in perception of quality of care:

‘If I cannot I will refer them to the health center, and make sure I accompany them to the health center, and after the child is treated I follow them up too at home to see if they are taking the medications rightly’—CHW—Kumba.

Supervisors received refresher training and supervisor manuals. They were supported to complete the CHW competency checklist to help them report on CHW performance, monitor improvement and to plan their work to provide more attention to poorly performing CHWs.

Across all sites, CHWs reported that supportive supervision positively impacted their performance, due to the guidance and feedback they received from their supervisors during the visits. Across all project sites, CHWs were praised for their passion and hard work in ensuring families followed preventive practices and sought care for suspected malaria. CHW services were trusted and CHWs more motivated.

“Our supervisors use the guide during every visit, and it helps them cover everything they need to check”—CHW, Ekondo Titi

“Yes. The community trusts them. Especially when you’re not in good health, you even know that the person works at a certain place. Sometimes, if it’s not service hours, you follow the person home. No. That means things are going very well”—female counsellor, Littoral

How the availability of CHWs affects utilization of their services

Combining the three interventions, firstly, COPHA to raise awareness of CHW services, secondly support to supportive supervision of CHWs to facilitate trust and thirdly, the provision of vouchers to support demand helped increased utilization of services and motivation of CHWs.

“I want to thank the organization for this project because it has made me proud in my community so much that even when I pass some mothers will say ,’if not of me my child will die of malaria because I did not have money you gave me a book I took to the hospital and my child was treated for free, thank you my sister’ I am really happy because I am appreciated in my community they even look at me like a god”—CHW, Kumba

How the affordability CHW services affects utilization

Provision of vouchers with additional support enabled communities to access care and value government services.

“With the [Breaking Barriers] project now, because of treatment, they are happy to go because they know that they will not spend. At least that one has helped them to even know the value of hospital, instead of sitting in the house and dying. And most of them are really testifying for the best treatment they have been having”—female District Centre de Sante Officer, Kumba

Vouchers were provided for all members of the community but the key objectives were to ensure improved access to care for displaced communities (IDPs).

“Number one change is that at least people now can go to the hospital. Because before, even if you give them a term to go to the hospital if they are sick, they will not go’– female community member, Kumba

IDPs benefited equally, subject to location and availability of services, disseminating information on voucher services through their community.

“I don’t know how to explain. If you talk about the IDPS’, patients, they are using it. They have been going to the health centre. For the vouchers. They have been going there. They give them treatment. They treat them. So, they are aware. Even if they come back without any meeting, they themselves do the sensitization because they discuss it”—male community leader, Kumba

Theme 3: Participants’ experience of each of the interventions;

Participants’ experiences were categorized experiences in relation to fidelity, implementation processes, reach, challenges, and participants responses for the three interventions, CoHPA, supportive supervision and provision of vouchers. Extensive responses were collected, collated, analysed and coded so only key responses for each intervention are reflected.

Fidelity

There was good fidelity for all three interventions. CoHPA  meetings and 70% of action plans were completed with equitable attendance between host, returnee and displaced with participation between male, female and including people living with disability and pregnant women and carers. Community leaders, supervisors and CHWs supported volunteers to plan, schedule and deliver meetings and plans.

“The counsellors make sure the action plans are not just talked about but carried out in the community”—male CHW, Tombel

“It’s up to all of us to make sure the actions we plan are followed through, not just the health workers.”—male community member, Kumba

For the supportive supervision intervention, supervisor visits to CHWs at their place of work were completed and appreciated. Participants reported that supervisor visits and activities were appreciated by CHWs and contributed to trust by the community.

“Yes, I always do home visit with my supervisor. Sometimes, after carrying out my home visits, he makes me understand that I did well, but I failed in some respects because I talked about mosquitoes, but I did not go in to verify them. He also mentioned that I did not ask about the vaccination card and also that I missed finding out if the host was pregnant or expectant of another child. So, I gained some knowledge on that to help me prepare the woman for ANC in the advent of another child. So that is the awareness that I gained”—CHW, Muyuka.

Regarding the health vouchers, voucher information was effectively communicated through CHWs, CoHPA meetings, and home visits, targeting the most vulnerable groups, including mothers, children, and the elderly. Utilization was largely centred around accessing malaria-related services, though logistical and security challenges, affected full redemption.

“Most households here receive vouchers, and it has made a big difference in helping people access health services.”—CHW, Ekondo Titi

Implementation process

The factors identified that were key to improving the programme were the selection process of the volunteers, the quality of the selection process determined the quality of the volunteer facilitating COPHA meetings, their delivery and facilitation, the presence and input of the CHW and management of feedback through the meeting scorecard.

“During meetings we identified two to three participants whom the charged with evaluation of the meeting and they did so independently without any influence and from their grading we identified what did not go well so as to improve in the next meeting”—male Chief of Centre, Littoral

“I just want to say even though the system of the scorecard was introduced. However, from the start of the project to the end of the project, we have never gotten any feedback from the scorecard. Maybe they will get some or maybe everyone who scored has a good score. If everyone had a great score, there would be feedback…But concerning that scorecard, whenever it was scored and taken away, we never had any positive or negative feedback from it”—CHW, Muyuka

However, participants reported completing the competency checklists at every visit was not helpful and the reporting tools were cumbersome.

“The guide is helpful, but we need more training on how to use it in situations where time is limited or when there are other problems to solve.”—CHW, Littoral

“My priority is that we should go into the field and work. Let us not sit on the table and work with papers and what you don’t know”—Female Chief of Centre Tombel

The voucher system was affected by stockouts, lack of acceptance by facilities and, in lack of services in highly insecure areas.

“Sometimes the health centres don’t have the supplies we need to redeem the vouchers, so even when we have them, they’re not always useful.”—female community member, Littoral

“My problem is those where the health facilities are not around because you might find difficulties in coming up to Ekondo Titi whereas if they were on seats, for example, those in Illor, it would be easy for them. In short, the problem is for the operational ones, it’s sufficient but for those areas where for one reason or another, they have left their posts and they’re somewhere else, I don't think it’s sufficient—male District Centre de Sante Officer, Ekondo Tito

Reach

Attention was paid to the inclusion of all key groups and at-risk participants in CoHPA meetings. There was a challenge to include men as malaria was considered a health issue where women played a greater role, particularly for child health. However, gender differences in attendance were equally related to different workloads as well as their interest levels. Meeting planners and facilitators worked hard to ensure the participation of men in a context where women would be the majority of attendees for most meetings.

“I try to encourage women and men to attend the conversation, especially when we are discussing about ANC, so that they should know the importance of ANC, they should know the importance of early status to tender women for ANC. Yeah, they always encourage them to attend…Equally. It’s not gender-based’—Male Chief of Centre, Ekondo Titi

The programme monitored participation by people living with disabilities.

“In an area where in a zone where the community has disabled people, they always used to be invited. Even though they are not many”—male Chief of Centre, Ekondo Titi

The majority of community stakeholders described joint participation and engagement of displaced, welcoming their participation, Ekondo Titi, Myuka, Kumba. Some participants from communities like Littoral, and Kumba described how it took time for the displaced to feel confident enough to attend CoHPA meetings and community leaders and CHWs described the work involved to make displaced feel confident. Some districts Tombel, Myuka, described how displaced were a significant group involved in CoHPA meetings and listed them among the groups with the most to benefit.

“Already, the CoHPA is welcome in my community. Because in my community, I have a lot of IDPs. So, before, it was not easy for them to join us. But thanks to the CoHPA meeting, we already live as a family. It wasn’t easy at the beginning but now CoHPA has brought them back to us. So, when they even have problems, they can ask someone else for help. As they always used to say, they are anglophones, we are francophones. Well, it wasn’t easy when it’s family–oriented but thanks to the CoHPA meeting that we organize every month, it means that we are family. So, we live as a family with IDPs. So, no more problem. And to do the CoHPA, I’ve always been in the habit of counting them more, the IDPs, because I bring them back to us. I don’t count them anymore”—male community member, Muyuka

While the voucher system improved access to care, the vouchers did not reach areas where distances were too far, and facilities were not functional because staff had abandoned their post.

“My problem is those where not on seat at the health facilities that are not around because you might find difficulties in coming up to Ekondo Titi whereas if they were on seat, for example, those in Illor, it would be easy for them. In short, the problem is for the operational ones, it’s sufficient but for those areas where for one reason or another, they have left their posts and they’re somewhere else, I don’t think it’s sufficient”—male District Centre de Sante Officer, Ekondo Titi

Challenges

The main challenges community members faced in attending meetings were due to insecurity and poor weather conditions. Security challenges were managed by planning meetings on days that posed lower risk while challenges linked to bad roads and weather were more difficult to manage.

“When security becomes an issue, we have to postpone or cancel meetings, and it’s hard to get the word out in time.”—male community member, Kumba

“Sometimes we can’t make it because of the roads, especially during the rainy season, but we try our best.”—female community member, Muyuka

Participants also reported that supervisors were constrained by time and budget, but the main constraints to CHW performance were their workload and that of their supervisors. Supervisors worked hard to complete their tasks seeking support, but they faced challenges. Supervisors were not given any incentive or renumeration for additional transport.

“I think if they are, like I earlier said, if they have a maybe a good per diem that can enable them to reach, at least to reach this area, then it will be possible. At least the information now will be covered in their places, in their locality that they are living”—male counsellor, Ekondo Titi.

Supervisors valued the training given during the programme and wanted more regular training and peer support.

“We received just one training, just the beginning of the programme. On what is expected from us. That was just one, but I think it’s always good to have capacity building after a period of time. ……..Also, to build our capacity. I think that is also necessary sometimes for us to have this capacity building where we can still have a common ground with other people to Share our best practices and maybe our challenge is to be able to learn from best practices of others, and generate solutions to the challenges we face in our community”—male District Centre de Sante Officer, Muyuka

Supervisors found paper reporting forms challenging and wanted to improve them.

“The supervision tools were too voluminous, but we made efforts to go through and fill all the required information”—male Chief of Centre, Littoral

“It’s very useful. These tools are really useful, and we place them in the work of the Agent de Sante Communitaire. Because the bonus, when we give them these tools, is to have a refresher where we explain everything to them as if they were naked. I said old mentalities will change. As a result, it requires very few tools…It’s just that the document is very rolly. [lengthy]. So, if there is a way to reduce, eliminate, eliminate the essential in a few words, it could reduce the volume and make it easily usable” female District Centre de Sante Officer, Littoral

The conditionality of vouchers for severe malaria and lack of coverage for co-morbidities were the main constraints and key requests were to extend the age range to older children and pregnant women.

“In my community, many of the patients don’t like to visit the facility because they are afraid of identifying other underlying conditions which will require them to spend more and as such, most of them request home treatments”—CHW, Muyuka

“There are also pregnant women who are not taken care of in this project, and we would like them to be taken care of as well’—CHW, Littoral

Participant responses

Despite these challenges, attendance at CoHPA meetings and completion of action plans continued, evidenced by project monitoring reports. Participants felt the reason for this was that people valued the results in malaria management, that is, an improved environment, net use and early treatment-seeking behaviour and they perceived an improvement in the motivation for their CHWs to support services.

“We see the results in our health, so we keep coming to the meetings.”—female community member, Ekondo Titi

“It helps when the CHWs visit between meetings; it keeps us engaged with the messages.”—CHW, Muyuka

Theme 4: Perception of the sustainability of CoHPA, supportive supervision and voucher system

Participants’ perceptions were categorized by participants experiences with all three interventions and their reflections on the sustainability of the programme, and how the interventions could be beneficial to communities. Participants responses were coded within each of the intervention: CoHPA, health vouchers and supportive supervision.

CoHPA

Communities described the impact of CoHPA sessions on knowledge and a commitment to continue awareness raising but a concern that without continued direct resource support, community activities will not continue.

Participants across project sites largely perceived the CoHPA approach as sustainable, with most attributing its success to active community engagement, the provision of adequate resources and its role in empowering communities to take responsibility for their health outcomes. Communities described the impact of CoHPA sessions on knowledge and a commitment to continue awareness raising but a concern that without continued direct resource support, community activities will not continue.

“[Breaking Barriers] project has done a lot…You know with the CoHPA meetings communities have decided to take the initiative by doing their own, making their own action plans whereby they clean bushes around. They go to the extent of even giving fines to people who do fail to keep their environment clean. I think all these were taken just as a result of the CoHPA meetings”—female Chief of Clinic, Muyuka

In Kumba, concerns were raised over the impact of insecurity on CoHPA’s sustainability. Across all sites, participants agreed that CoHPA’s long-term sustainability requires sustained investment in capacity development, community mobilization, and resource allocation.

“CoHPA has given us the tools to improve our health, but we need continued support and resources to keep it going”—CHW, Ekondo Titi.

Supportive supervision

Some participants reported that they would still use the CHW services beyond the end of the voucher system,

‘Yes, they can still use it [CHW service] because it will help. If the voucher system ends and you really want your child to be well, you can dip your hand in your pockets despite that the voucher system is no longer there but if the voucher system is still there it will help us very much’ _female community leader Tombel.

‘People will still continue using CHW but it will be at, at, at a lesser rate. It will not be like when there was these vouchers available for their free payment. So, when they come one or two that normally they rate at which people using reduce but it cannot stop’ -male counselor Tombel.

However, in other communities, CHW services were not sustained without external support.

‘Because you people have stopped the project. The project has ended. They were active because you engaged them. And other NGOs too. So, most of the NGOs, they have closed. So, she don’t work’- male community leader Kumba.

The voucher system

Participants across project sites expressed concern about the sustainability of the voucher system particularly in terms of long-term funding and resource availability. While participants praised the system for improving access to health services, they questioned its viability without continuous financial support.

“The voucher system has made a big difference in helping people get care, but we need to make sure it doesn’t stop due to lack of funding.”—CHW, Muyuka

Discussion

This study explored changes in people’s perceptions and experience of malaria and their ability to prevent and control the disease in their communities following the implementation of three community co-designed interventions. The formative research found that malaria had a major impact on conflict-affected populations in Cameroon [6]. In this endline study, participants said they valued the support they had received through the three introduced interventions, and these empowered them to undertake prevention activities, engage with CHW services and had enabled them to access malaria services. While malaria remained a key concern, communities reported they were taking action to clear mosquito breeding sites and to encourage higher use rates of bed nets through various measure including, meetings, house to house visits to check on use and to support households with elderly and people living with disability to hang nets and even to fine those who were not using them. Participants reported experiencing fewer child deaths in their communities during the intervention period.

The introduction of the three innovative interventions together with advocacy and support for last mile drug distribution by REO resulted in an impactful intervention; vouchers for subsidized care were well received and increased health-seeking behaviour and the associated supportive supervision and CoHPA activities improved awareness and access to services. The programme was planned to coincide with a mosquito net distribution by the Global Fund and both programmes will have generated increased net use, therefore the design of Breaking Barriers was not meant to attribute increased net use to the programme alone. The intensity of the conflict did lessen during the programme period, which would have improved population movement and access to preventative and control services and reduced the number of people forced to live in the forest for periods of time. Nevertheless, the combination of the three interventions was positively received and participants experienced benefits.

CoHPA was perceived as a valuable approach for raising awareness of malaria and encouraging good prevention and treatment behaviours and combined well with interventions that improved access to and quality of community health services. CoHPA is an adaption of the Community Dialogue Approach, the process of co-creation by community stakeholders enabled the Community Dialogue Approach to be presented as a potential intervention component and adapted by community members and other stakeholders to meet their circumstances. The Community Dialogue Approach was adapted from the Integrated Model of Communication for Social Change, an iterative process where “community dialogue” and “collective action” work together to produce social change in a community that improves health and welfare [12]. The Community Dialogue Approach has been shown to be effective to address health information gaps and support communities with collective decision making for improved health practices [13, 14]. This approach has also been found to be feasible in resource-poor settings, well-received by the population and to improve knowledge at population level [14]. To our knowledge, the CoHPA model is the first evidenced-based community-led meeting model used in conflict-affected areas for critical decisions to fight malaria. While communities expressed a strong desire for CoHPA to continue, they acknowledged that sustaining it without external funding would be challenging.

The presence of CHWs and their supervisors at CoHPA meetings, and their regular support to communities, increased trust in CHW services. At endline, community members were better able to explain the impact of malaria and articulate the actions they were taking to manage it, as a result of the CoHPA meetings held during the intervention phase. Similar to findings by Martin et al. [13], communities discussed the nature of the problem, its causes, emerging issues, and over time developed activities to address these challenges.

Participants reported a reduction in malaria deaths, particularly among children, and perceived a broader reduction in malaria morbidity and other illnesses due to community-led cleanup campaigns and more timely utilization of health services. The Breaking Barriers project was credited with improving knowledge and practices around malaria prevention and control, leading to sustained personal and community cleanup campaigns, improved mosquito net use and care, and increased, more timely engagement with CHW services. CoHPA also provided a platform to create demand for CHW services and reinforce supervised CHW activities supported by voucher schemes.

Participants described knowing their CHW by name, trusting their services, and recognizing their supervisors. A small study from Belgium noted that trust in CHWs stems from recognition, equality, and reciprocity, as well as a client-centred approach and strong links to health facilities [15], factors also reflected in our findings. Communities valued the regularity of CoHPA meetings, their participatory and action-oriented nature, and the opportunities they provided for feedback and continuous improvement. Participants compared CoHPA favourably with past health education interventions, which they described as one-off meetings with limited opportunity for engagement or follow-up. CoHPA’s regular structure allowed participants to catch up if meetings were missed and enabled communities to design and adapt activities based on their evolving needs for example, conducting door-to-door bed net checks, supporting vulnerable households, fining non-compliant households, and testing participants for malaria during meetings to visualize local transmission dynamics. However, while CoHPA facilitated local action plans, greater support for engaging local council leadership and increased funding for planning meetings may enhance its sustainability.

Supportive supervision of community health workers and promotion of their services increased trust by their communities in their services, and this subsequently raised their motivation. Engagement with CHWs have been shown to be an effective way to maintain access to health services during conflict events [16]. As a result of the Breaking Barriers interventions, communities appreciated seeing CHWs as a team, supported by supervisors, engaging in CoPHA and subsequently, trust in their care increased. These are all facets of the approach to supportive supervision in the programme. CHWs valued the face-to-face supervision as it was an opportunity for mentoring and knowledge exchange. Supervisors valued the support received to engage with their manager and to receive refresher training and guidelines. They face challenges with their workload, with support for their travel, and their reporting system is burdensome. A systematic review by Rowe et al. [17] found training and supportive supervision as essential components for any programme seeking to improve the quality of community health services but real performance improvement is achieved when these elements are combined with improvements in infrastructure and systems. In this study, supportive supervision was said to have increased community engagement and use of the voucher system but the effect was limited by the remaining challenge of interrupted drug and medical supplies, limited opportunities for training of supervisors and the lack of health infrastructure in highly insecure communities [17]. CHW performance is mediated by connection with health services [18]. CHWs and supervisors played a strong role in the provision of vouchers, supporting their use, explaining the criteria for their use and resolving issues related to late delivery.

Despite government policies supporting provision of  free malaria treatment for children under five and pregnant women, participants reported persistent cost barriers to accessing services. The voucher system was widely perceived as effective in increasing access to and utilization of health services, particularly for simple malaria treatment at community level and for transport during severe malaria cases. Many studies provide evidence on the impact of cash transfers, and the role of specific cash transfer design features and implementation variables in shaping outcomes for maternal and child health and infectious disease [19, 20]^. However, in delivering vouchers for severe malaria there is a need to consider co-morbidities and treating malaria in older children. Plans for voucher services in humanitarian settings need to consider the availability of the health service in high conflict areas. In highly insecure areas, vouchers may not be sustainable unless they are integrated into national or local health system plans. Future research should explore how local councils could be supported to institutionalize voucher schemes, potentially by including them as agenda items in budget review sessions to secure small but sustainable allocations. At endline, communities continued to see malaria as a major concern, but their descriptions reflected greater awareness of risks, prevention practices, trust in community health services, and the benefits of financial support to access care. This marked a shift from baseline findings, where communities primarily cited frequent illnesses, financial barriers to treatment, and environmental factors like stagnant water and dirty surroundings. Although cash transfer interventions provide rapid benefits, their short-term introduction may limit long-term impact if sustainability mechanisms are not established. Ensuring services are free at the point of care and properly administered remains critical to reducing reliance on alternative or informal healthcare options.

Overall, the intervention model was effective and could be a strong community intervention for malaria prevention and control in Cameroon and for the continued humanitarian risks. Cameroon continues to be affected by the crisis in the Southwest region. As of September 2024, there was an estimated 155,149 IDPs and 190,922 returnees in the Southwest and 159,300 displaced hosted in the Littoral and West regions. Access to malaria services is constrained by limited functional health facilities, poor supply systems and financial barriers faced by the affected population [21]. Furthermore, Cameroon is highly exposed to climate change impact and shocks [22]. This approach of combining community dialogue, support to improve quality of care by CHWs and subsidized care is a valuable programme to support resilient community health services.

Strengths

The research protocol supported quantitative, qualitative and process data collection and analysis enabling us to evaluate the impact, reach and make practical recommendations for malaria prevention and control. The study was ambitious in studying 80 conflict affected communities over 18 months and it was the existing connections between REO and KASAFRO that ensured this was possible. The process of formative research, co creation, evaluation and adaption together with community funds to support agreed community actions enabled the study to explore how funding community planning, promotion and evaluation is more effective than provision of information alone. The combination of funding the adaptation and provision of existing supportive supervision guidelines and associated training and CHW engagament in CoHPA increased trust and utilization of CHW services. These two elements, CoHPA and supportive supervision, promoted malaria prevention and services and the vouchers improved access. Data was disaggregated by gender and by host, displaced and returnee and reviewed regularly; communities felt CoHPA supported engagement between these sectors of the community. The research was relevant and coherent, studying three interdependent interventions identified and supported by Global Fund and NMCP and funded by Expertise Francais with sufficient engagement and flexibility to allow for adaptations including additional expertise and drug provision.

Limitations

The limitations of the study were related to conducting research in a conflict-affected area where access was challenging. Several limitations should be considered regarding the interpretation of the findings. Questions asked in FGDs were numerous because of the desire to evaluate impact and process so not all questions asked were the same across different regions. Each region and community experienced conflict in a different way with respect to the number of displaced, access to health services and levels of security and the focus of the discussions reflected the experiences in the locations; so, some answers may not reflect the experience of all five districts, the study identified each participant by district to reflect this. The difference between the study participants and the research team: gender, culture and language could have impacted on the experiences described in this study due to power dynamics and interviewer reflections. Field supervisors conducted some of the interviews and their involvement in the programme could have influenced participant responses.

Conclusion

Malaria is a major health concern in Cameroon. Across all project sites, participants’ prevention and health-seeking behaviour was reported to have improved significantly due to the combination of community-based interventions introduced by the Breaking Barriers programme. Community members were supported to address barriers to accessing to care such as availability services, affordability of treatment, distance to health facilities, community awareness and health-seeking behaviour, managing their solutions and progress evaluation equally across conflict affected communities with the exception of those living in highly insecure areas. Further studies with greater involvement of local council structures and a more detailed comparison with community score cards will assist in further developing the intervention together with analysis of cost and value for money to help stakeholders to consider investing in the approach. Supervisors and community health workers respond well to training, resources and connection with primary health care services. Cocreation of guidelines and job aids, digital tools and support for peer mentorship could further improve the service. The voucher system was effective, but children presented with co -morbidities that still required payment, older children and pregnant women were in equal need. Vouchers were not as effective in areas of high conflict where the health system was damaged; referral services were needed and CHWs needed to connect with the health system. Research should continue to refine the interventions to ensure their effectiveness and scalability in appropriate conflict affected settings so adoption by MoH is made possible.

Abbreviation

CHW

Community Health Worker

CoHPA

Community Health Participatory Approach

FGD

Focus Group Discussion

GFATM

Global Fund for AIDS, Tuberculosis and Malaria

IDI

In-depth Interview

IDP

Internally Displaced Populations

LIC

Low Income Country

MC

Malaria Consortium

MoH

Ministry of Health

NGO

Non-governmental Organization

NMCP

National Malaria Control Programme

NSP

National Strategic Plan

RA

Research Assistant

REO

Reach Out NGO

UNOCHA

The Office for Coordination of Humanitarian Affairs

WHO

World Health Organization

Author contribution

B. E.O. gave substantial contributions to the conception, design and implementation of the study, significant contribution to the collection, analysis and interpretation of data for the study, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. B.M.Y gave significant contribution to the implementation of the study, significant contribution to the collection, analysis and interpretation of data for the study, final approval of the version to be published. O.O.O gave substantial contributions to the implementation of the study, significant contribution to the collection, analysis, interpretation, visualization of data for the study, contributed to first draft of the manuscript and contributed to the revision of the manuscript, final approval of the version to be published. L.D. and E.J and H.C gave significant contribution to the conception and design of the study, final approval of the version to be published, H.H gave substantial contributions to the conception, design and implementation of the study, provided substantial revision of the manuscript, final approval of the version to be published. K.M and E.N.O gave significant contribution to the conception, design and implementation of the study and final approval of the version to be published. K.B gave significant contribution to the implementation of the study, revision of the manuscript and final approval of the version to be published. Y.Z gave substantial contributions to the conception, design and implementation of the study. Final approval of the version to be published. E. A. T and B.M.N gave substantial contributions to the design and implementation of the study, significant contribution to the acquisition, analysis and interpretation of data for the study, contributed to the revision of the manuscript, final approval of the version to be published. A.M contributed to the conception, design and implementation of the study, significant contribution revision of the manuscript, final approval of the version to be published. I.N and K.G gave significant contribution to the implementation of the study and to the acquisition of data for the study. Contributed to the revision of the manuscript and final approval of the version to be published. A.D and E.C and N.S and S.A and J.P, contributed to the implementation of the study and significant contribution to the acquisition of data for the study final approval of the version to be published. A.O.T, B.T.I contributed to the implementation of the study and final approval of the version to be published. S.W contributed to the design and implementation of the study and technical support and final approval of the version to be published. E.B gave substantial contribution to the implementation of the study and to the acquisition of data for the study, analysis and interpretation of data. Provided significant revision of the manuscript, accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved and final approval of the version to be published. E.J contributed to the conception and design of the study and final approval of the version to be published. L.A.O gave significant contributions to the conception, design and implementation of the study, substantial contributions to the revision of the manuscript and final approval of the version to be published.

Funding

Funding was provided by Expertise France under the 5% initiative.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent for publication

Ethical approval was sought and obtained from the Institutional Review Board of the Faculty of Health Sciences of the University of Buea, IRB00008917. Administrative authorization was obtained from the Southwest Regional Delegation of Public Health and the District Health Services in all study sites. Written and verbal informed consent was sought from all study participants.

Informed consent

It is important that you are able to give your informed consent before taking part in this study and you will have the opportunity to ask any questions in relation to the research before you provide your consent. By signing it you are telling us that you: Understand what you have read. Consent to take part in the research project. Consent to the use of your personal and health information as described. You will be given a copy of this Participant Information sheet and Consent Form to keep.

Consent to participate

Consent was obtained from all participants using the information sheets and consent forms.