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

Background: Onchocerciasis affects some of the world’s most marginalized people, perpetuating poverty and inequalities. Mass Drug Administration (MDA) with Ivermectin has taken place within the Meme River basin region in Cameroon for over 15 years. Despite this, onchocerciasis is still prevalent in the region due to existing and emerging contextual challenges. Using a social-ecological approach we explore the everyday realities of communities, highlighting the challenges and potential solutions that could support Neglected Tropical Disease (NTD) programmes when transitioning from control to elimination of onchocerciasis in this highly endemic area and other similar communities. Methodology/Principal finding: In-depth interviews (71) with community members and Community Drug Distributors (CDDs) were conducted to understand current knowledge, attitudes, and behaviours in relation to transmission, prevention and treatment of onchocerciasis. Through application of the social-ecological model, four key themes were identified: 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social determinants (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental determinants (exposure, housing, occupation and poverty); and 4. health seeking pathways and decision making for treatment (access, cost and preferable treatment routes). Conclusion/Significance: NTD programmes need to respond to diverse community circumstances and behaviours. Communities are not a homogeneous risk group and treating them in this way will delay elimination. A deeper understanding of individual needs and their capacity to seek prevention and treatment must be considered if onchocerciasis is to be eliminated and the remaining impacts managed. Author summary: In Cameroon, within the Meme River Basin, ending the disease onchocerciasis, also known as river blindness, remains a health challenge, despite over 15 years of distributing the prevention and treatment drug called Ivermectin. The ongoing occurrence of the disease in this region highlights that moving from control of the disease to elimination is complicated by many factors. This research found four areas that impact on disease risk, prevention, treatment, experience and health seeking behaviour. These are 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social factors (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental factors (exposure, housing, occupation and poverty) and 4. health seeking pathways and decision making for treatment. These are also affected by gender differences and community participation and ownership. We recommend the following for policy makers; intersectional and gender analysis at the local level, addressing environmental risk factors through integrated and regular health promotion, vector control strategies and access to safe water sources; action to minimise social and economic barriers to MDA; case detection and management that also addresses stigma and a fair and just support network for CDDs.