From COVID-19 to Mpox, How Can We Engage Communities in Cameroon?

Introduction

Risk Communication and Community Engagement (RCCE) is a pillar for Public Health Emergency (PHE) preparedness, response and resilience [1-2], and is one of the core capabilities of the International Health Regulation (IHR) 2005 [3-4]. It enables authorities and experts to listen and respond to citizen’s concerns and needs, ensuring that the advice provided is relevant, trustworthy and acceptable [5-6].

In Cameroon, recent health crises such as the COVID-19, cholera, yellow fever and Mpox epidemics have revealed major challenges for the efficient implementation of RCCE in context of limited resources and socio- cultural diversity [8]. Indeed, several evaluations (IAR1, AAR2) 1have noted the need to strengthen the commitment of community actors by improving the communication strategies used to raise awareness among at risk populations based on evidence [9-12].

With this in mind, we conducted a study to identify the most influential communication channels and tools for RCCE on COVID-19 and other public health events in Cameroon. The aim of this article is to present and analyze the most suitable communication channels and tools in a socio-culturally diverse country like Cameroon.

Methods

Type of Study

We conducted a cross-sectional parallel convergent mixed study.

Study Setting

The study took place over three months (October-December 2023) in two Health Districts (HD) in each region of the country, considering urban-rural specificities.

Participants and Sampling

For the quantitative component, participants were at least 18 years old, permanently residing in Cameroon since March 2020. Those refusing to complete the questionnaire were excluded from the study. Sampling was carried out at national level using stratified single-stage cluster sampling, with each region representing a stratum. Clusters were made up of urban and rural neighborhoods and villages in the selected HD. The number of clusters depended on the target population in the Health District. The sample size calculated at national level using the Lorentz formula was allocated by region, considering the demographic weight estimated by Central Office of Census and Population Studies (COCPS) 2019 [13]. A total of 10,400 people took part in the household survey via an electronic form on Kobo Collect, accessible from tablets or any other online device. A maximum of five people was interviewed per selected household. For the qualitative component, semi-structured individual interviews and Focus Group Discussion (FGD) were organized in all regions, using discussion guides developed by the research team. Refusal to participate and inaudible recordings led to exclusion. The individual interviews concerned resource persons involved in RCCE implementation at regional, HD and community. In each region, six FGD were conducted with young adolescents (aged 18-20), young adults (aged 21 and over), pregnant women, elderly people with co-morbidities (HIV, hypertension, diabetes) and the general population. The qualitative data collected were recorded using Dictaphones with the consent of the interviewees in an appropriate space. A total of 111 individuals interviewed and 60 FGD were organized in all regions of Cameroon.

Study Variables

For the quantitative component, the variables collected on the communication channels and tools made it possible to identify those that were the most influential, considering the confidence of the participants. The determinants of the use of a communication channel and tools (gender, location, age, etc.), which could influence their choice, were also considered. For the qualitative component, semi-structured individual interviews and FGD focused on identifying the communication channels and tools with the greatest influence on participant’s behavior and analyzing the determinants of participants’ use of a communication channel and tools.

Data Analysis

We analyzed the quantitative and qualitative data independently, but their different results were interpreted together. Descriptive and statistical analyses of the quantitative data were carried out. Bivariate and multivariate logistic regression and chi-square tests were used to measure associations between variables. The P-value at 5% was used to identify a statistically significant difference. Analyses were performed using Python 3.12 and Excel. The qualitative data were transcribed using Word software, categorised by item and analysed using N-Vivo software. Data analysis was based on data oriented towards the study objectives.

1 Intra Action Review of the management of COVID-19 in 2021 and 2022, RIA of the management of cholera in 2023.

2 After Action Review of the management of the Africa Cup of Nations Total Energies 2021 in 2022.

Ethical Considerations

This study was approved by the National Ethics Committee of Cameroon under reference number Nº 2023/10/1593/CE/ CNERSH/SP. It was also approved by the Centers for Disease Control and Prevention (CDC) Atlanta as a public health activity. No changes to the protocol were made after ethical clearance was obtained.

Role of the Funding Source

CDC Atlanta played a role in study design, data collection, data analysis, data interpretation, report writing and article writing.

Results

Quantitative Component

Socio-Demographic Characteristics of Participants

A total of 10,400 people was interviewed, and 5,41 households visited in all regions. The most represented regions were Centre1973 (19%), Far North1810 (17.4%) and Littoral1477 (14.2%). The median age of the participants was 32, with an Inter-quartile range of 25 to 43. The sex ratio (M/F) was 0.94:1 indicating a slight preponderance of women. Most of the participants were married, 4938 (47.5%), and the most common level of education was secondary, 4891 (47%). Finally, the Christian Catholic religion was most represented with 3803 (36.56%) (table 1)

                    Table 1: Description of the Socio-Demographic Characteristics of Participants

Communication channels and tools most influential on participant’s behavior

The most used by participants are television (23.56%), radio (21%) and social networks (15.91%), regardless of age group (table 2).

Table 2: Distribution of the Most Frequently Used Communication Channels Among the Population Surveyed, By Age Group

In terms of trust, television is most reliable for 28.71% of participants, followed by radio (22.39%) and social networks (10.39%), regardless of age. Those living with comorbidities trusted television (30.59%) and radio (24.03%). Health information provided by public health (34.12%), community (22.20%) and religious (16.07%) leaders are the most reliable (table 3).

Table 3: Description of The Means of Communication Trusted by the Populations Surveyed, By Age Group

The most attractive communication tools were posters (7,143 or 42.79%) and banners (3,889 or 23.39%) for all age groups and all genders. Regarding acceptance to COVID-19 vaccination, 3154 (30.32%) participants were vaccinated. Radio (21.67%), television (20.63%) and Community Health Worker (CHWs) (9.65%) were the most frequently used communication channels.

The health information provided by public health leaders (34.12%), community leaders (22.20%) and religious leaders (16.07%) was the most reliable for participants. Posters (42.97%), banners (18.7%) and flyers (16.76%) were the most attractive tools (figure1).

                       Figure 1: Communication Tools Most Used by Vaccine People

Determinants of the use of Communication Channels and Tools

The use of communication channel was statistically influenced by the presence of comorbidity (P < 0.001; OR =- 0.44 [-0.64 - - 0.24]), and the use of a communication tools by level of education, notably secondary (P < 0.001; OR =0.42 [0.24 - 0.59]) and university (P < 0.001; OR=0.42 [0.20 - 0.65]). It was also influenced by the Eastern region (P < 0.001; OR =1.44 [0.49 - 2.40]), the Far North (P < 0.001; OR=0.98 [0.50 - 1.45]), Littoral (P < 0.001; OR =-0.66 [1.06 - 0.26]), North (P < 0.001; OR=-0.76 [1.16 - 0.36]) and South (P < 0.001; OR =1.37 [0.42 - 2.33]). (table 4)

Use of a communication tools                  ORa                   P-value                     CI 95%

                  Table 4: Description of Variables According to Multivariate Regression on The Use of

Qualitative Section

Three main topics emerged from the interviews: involving the most influential resource people in communication, capitalizing on community spaces, and capitalizing on influential communication channels and tools.

Involving the Most Influential Resource People in Communication

Several participants felt that community, traditional and religious leaders are better placed to deliver effective communication within the community, because the population trust them, and they are role models.

‘’(...) in a group where the traditional authority does not agree with what you come to do they also have their means of communication to influence the communities not to accept what you bring, you are not going to see people running to start telling people here is the chief says that they’ (Es_EI_PFR_17/11/2023)’’

Journalists were seen by some participants as influential, as they conveyed a reliable and trusted message. They felt that the risk of misinformation coming from them was low, because they verify it.

“I consider information from Journalist those I know because I think they cannot give information that is not verified so when I see information from them, I take it very serious.” (NW_FGD_ FE_21/11/2023)

Healthcare staff were the people authorized to maintain effective communications within the community. Several participants had taken the example of the influence of the message given by personnel during the COVID-19 pandemic. CHWs are people who can communicate and convey information quickly because they are constantly in contact with the community, also with leaders who trust them on the quality of the message. In addition, the type of messages to be conveyed must be adapted to each community. The local language must be used to ensure that the information is accessible to all, especially in rural areas.

“« You have to speak their language [...] Today, you have to design targeted messages […]” (Es_Ei_PFCR_15/11/23)

Capitalizing on Community Spaces

In all regions of Cameroon, the physical gathering spaces known as community spaces were identified as the most influential spaces for communication. These were diverse, and included religious, residential, school, traditional (chiefdoms), community entertainment, hospital and commercial spaces. Although religious and traditional spaces were favored, residential spaces were more so, especially in rural areas.

“I say that wherever there are gatherings, in churches, hospitals, mosques, public squares, even markets”. (Ou_FGD_Fe_ R1_16/11/23)

Moreover, communication in hospital spaces was identified as a preferred communication space by pregnant women and people living with comorbidities.

Schools were presented as influential communication spaces for children and teenagers.

Capitalizing on Influential Communication Channels and Tools

Some participants stressed the importance of capitalizing on all types of radio and TV (public, private, local, national, international). “Uhhh to me I think the national station should not be used at a certain level because most people believe that the national station are just there to make money and just make stuff, so, there's a way we use private stations like equinox because most people believe in equinox more than they do believe in CRTV”. R3 (NW_FGD_ AGE_15/11/2023)

Others pointed out that radio and television were more suitable for the elderly, as they had become accustomed to trusting the information they heard. “Now for the elderly, we know that they like to listen to the radio and television, so we can use them to raise awareness. …” (Ou_ R1_FGD_Fe_16/11/2023)

Most participants agreed that social networks had a huge influence today. They are often at the origin of rumors circulating within the community, because they are followed, and some people hardly trust the information given by contacts. Young people were identified as the most influenced by social networks.

“...the age group most affected are those aged 20 and over what they use today are social networks, so we need to do some really digital communication to be able to reach this target group.” (Ce_ EI_PF_15/11/2023)

Visual communication media, particularly posters, were the most popular among participants. In fact, according to the participants, they use images to capture attention and better fix ideas in the minds of the target audience.

“For example, if you organise an educational talk with visual aids, people get on board, because they see, you bring them in, you show them gravity, it starts here, it ends there, if you don't do this, you'll have to do this with supporting images, and people get on board.”. (Lit_EI_LC2_16/11/2023)

Integration of Quantitative and Qualitative Results

There were no discrepancies between the quantitative and qualitative results of this study. Firstly, the results of both parts of the study showed that the most influential communication channels are television and radio. However, the new elements are the use of CHWs in the quantitative section and the use of social networks in the qualitative section. The study components also converged on the theme of identifying the communication tools most influential on participant’s behavior. Posters were the most attractive tools. In addition, both sections agreed that communication strategies should include a specific channel for people with co-morbidities. Finally, level of education and region were determinants of the use of communication tools by target populations recognized by both strands.

Discussion

Effective communication is an essential component for crisis management. Numerous studies demonstrate that trust in the news media and in governments is paramount in the context of a health crisis, as it acts as a protective factor [14-15]. Countries or regions with low institutional trust tend to have higher death and infection rates during the COVID-19 pandemic [16-17-18]. Pre-pandemic COVID-19 studies also found that when institutional trust is high in the population, people tend to comply with institutional norms and guidelines by following the instructions and recommendations of health authorities [19-20].

In our study, the analysis of people's confidence in the information disseminated diverges. This is illustrated by the fact that most participants stated that, in order of preference for information relating to the COVID-19, those coming from their community had priority. Indeed, community involvement was particularly effective when it was generated by CHWs. This aligns with a study conducted in Africa which found that individuals felt more able to be influenced by decisions made at community level (34%) than those made at national level (22%) [21-22-23]. This underlines the importance of the channel through which the message is disseminated, as much as its content. According to the study, CHWs are direct relays from the State to citizens. The capitalization of community spaces confirmed the importance of interpersonal communication within the RCCE framework for epidemics, pandemics and PHE in Cameroon. In fact, they emerged as the most influential spaces for communicating with the targets who frequent them. It is therefore crucial to maintain excellent proximity when communicating within communities and their citizens.

The results of a study on trust in institutions and the role of digital social networks in the context of COVID-19 in Cameroon in 2020 showed that Internet users prefer audio and audiovisual media for information on institutional communications or disease [24]. These results concur with those found in our study. Our results corroborate observations made in Uganda, where radio and CHWs were also trusted sources [25-26]. Although the study found that traditional mass media, particularly radio and TV, had the greatest impact, social networks also exerted an influence, particularly among young people.

Posters captured the attention of participants our study. This is because they are generally designed with attractive visual elements that facilitate understanding and engagement. By combining text and visuals, posters help to reinforce the memorability of health messages. This finding is reinforced by similar observations in Uganda, where posters and images were also preferred [27]. They are accessible without the need for advanced technology and can therefore be used in all regions. As a result, visual tools, particularly posters, should be prioritized in message dissemination strategies during RCCE in Cameroon.

Level of education and region were significant determinants of the use of communication media. Socio- educational, cultural and geographical factors influence the preferences and effectiveness of communication channels for disseminating health information. To optimize the implementation of RCCE, it is essential to take these factors into account to design media tailored to specific needs of different populations and regions. Co-morbidity status is a significant determinant in the choice of communication tools used. This observation reveals the impact of health status on the preference for an effectiveness of different communication channels for disseminating health information [28]. Communication strategies must consider the specific needs of people with co¬morbidities by designing adapted tools that offer integrated and personalized information. It is also important to use a multi-channel approach to meet the requirements of this population. It is essential to emphazise that community engagement mechanisms must be specifically adapted to the realities of local communities.

Despite the expansion of social networks, the so-called traditional media (television and radio) remain those most used by the Cameroonian population. Non-media communication, which is essential for engaging the population, must rely primarily on community leaders and local health workers. Visual aids should be prioritized and contextualized to socio-cultural diversity. Indeed, in rural areas, Mpox is primarily linked to animals and populations are often less educated, engagement should primarily occur through community leaders and CHW. In urban areas, where Mpox transmission, particularly with the clade IB currently circulating can occur through sexual contact, communication strategies should rely on mass media such as television and radio. This information should help improve communication strategies to empower Cameroonian populations at the course of public health emergencies, particularly Mpox.

Limitations

Although the study is national in scope, it was limited to a few cities in the regions and is therefore not exhaustive. Furthermore, it did not consider the print media, which are strongly represented in the country but not widely consumed by the population [29-30].

Acknowledgements

We would like to thank CDC for its technical and financial support for this study.

Funding: Centers for Disease Control and Prevention

References