Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected Anglophone regions of Cameroon

,


INTRODUCTION
Globally, many countries are experiencing a second or third wave of the COVID-19 pandemic, which is hitting harder than previous waves. 1Most countries are scaling up testing capacity for both symptomatic and asymptomatic persons.Yet relatively low infections are being reported in many African countries like Cameroon in part, 2 due to low COVID-19 testing rates. 3Cameroon is one of the most affected countries in Africa from the COVID-19 pandemic with 30,740 cases and 474 deaths as of the 31 st January 2021. 4In fact, from the 1 st to 31st January 2021 alone, 3,340 new cases were recorded, raising the case-fatality rate to 1.6%, the highest recorded since the confirmation of the first COVID-19 case in Cameroon. 4Testing rates and records at the start of the pandemic were relatively high in the first few months after the first case was confirmed on the 6 th of March 2020. 5Sadly, testing rates plummeted for several months although the number of testing sites for COVID-19 had been increased with the introduction of the COVID-19 rapid test kits at district levels. 2 It is uncertain what the true cause of this decline in testing rate was, despite efforts by the Ministry of Public Health to decentralise testing at primary care level.There were possibly asymptomatic people with SARS-CoV-2 who may pass undetected and symptomatic patients self-medicating at home with no records within the health information system (HIS) to enable adequate policy development and implementation. 2,6he on-going conflict in the two Anglophone regions in Cameroon (North West and South West Regions) further sets in challenge to COVID-19 testing in districts as 37% health facilities are reported to have been closed or partly functional.Since 2016, the South West and North West Regions of Cameroon have been experiencing armed conflict which has led to over 800,000 persons internally displaced. 7,8Provision of public health services in these regions are challenging owing to the high insecurity rates observed in these conflict-affected regions with some health facilities even burnt down by the warring factions.Faced with a partly non-functional health system in these regions, 8 especially within the era of a pandemic, there is need for strong reinforcement of COVID-19 infection prevention measures including COVID-19 testing at all levels, 5 especially at community level where transmission is likely to happen the most.This is key in mitigating the impact of COVID-19 in fragile and conflict-affected settings, especially considering that vaccination against COVID-19 in conflict settings may not happen soon. 9Thus, raising the need to strengthen policy efforts in scaling up COVID-19 testing within communities.We sought to investigate the awareness, health seeking practices and barriers to COVID-19 testing in the conflict-affected communities of the North West and South West Regions of Cameroon.

STUDY DESIGN AND STUDY AREA
A cross sectional survey was conducted in the North West and South West Regions of Cameroon.The study areas were selected because they are experiencing a protracted humanitarian crisis for the past four years with high insecurity causing over 800,000 persons to be internally displaced and a good number of non-functional health facilities.

STUDY POPULATION AND SAMPLE
The study population was made up of people residing in conflict-affected communities either as internally displaced persons or host populations.All study participants were above 18 years of age.The sample size was calculated based on the population size of 3,521,900 for the two regions, 10 using a margin error of 5%, a confidence interval (CI) of 95%, and an expected response distribution of 50%. 11The minimum sample size estimated for the study was 385.We enrolled a larger sample size of 872 participants in order to account for errors and non-respondents.
In both regions, convenient sampling method was used to recruit survey participants due to security constraints.

QUESTIONNAIRE
A questionnaire was developed to determine public awareness and identify some aspects, which may influence the uptake of COVID-19 testing in conflict-affected areas of North West and South West Regions of Cameroon.The questionnaire was pre-tested in one community and observations from the pre-test were used to improve the questionnaire.The questionnaire was divided in three sections, with the first section collecting information on the sociodemographic characteristics of the respondents, the second section collecting information on the knowledge and risk associated with COVID-19 and the third section on health seeking practices related to COVID-19.The health seeking practices of participants in regards to and during COVID-19 pandemic were also assessed in this study.On the participant's first point of care during the pandemic, a majority still preferred government hospitals (33%) of the different options while an interesting proportion (26.8) practised self-medication.On how the disease was treated for those who had been infected, only two had been to the different treatment centres set up by the government.We observed that an over whelming majority of the participants (87.4%) had never been tested for COVID-19 and therefore were unaware of their status.Unaware of their COVID-19 status, 95% of the participants however admitted having experience signs/symptoms related to the disease with 46% seeking no treatment at all as Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected... presented in Table 3.

UPTAKE OF COVID-19 TESTING
The wiliness to submit to a COVID-19 test was also evaluated in this study and responses from the 872 participants summarised in Table 4. Interestingly, a majority of the participants (61.2%) said they would readily go for the test if they presented with symptoms, irrespective of the sample collected (49.3%), and either at a government (36%) or private (25.9%) testing centre.However, 42 of those who took the test did not go for their results either due to no face mask, lack of funds, no identification document or did not know the location of the testing centre.

CONSTRAINTS TO COVID-19 TESTING
Accessibility to COVID-19 testing sites as well as other difficulties encountered by participants to get tested were captured and presented in Table 5.Of the many reasons advanced for not getting tested, a reasonable percentage of participants (14.6%) said they were scared of being quarantined, while others said they were sacred of being injected with the virus (6.9%) and of gunshots (1.1%).Also, a majority either did not have any sample collection site in their area of residence (37.6) or did not know of it at all (29.8%), while 28% said they would need to travel long distances before getting to a testing site.A quarter (25%) of the study participants said they were prevented from testing by the ongoing armed conflict in the regions as they were scared of Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected...This study took interest in the association between the participants' area of residence and some COVID-19 variables including whether the participant had ever been infected/ tested, if the participant will readily go for testing, knows / have testing sites and if the crisis was preventing their will to get tested (Table 6).We noted an over whelming majority of participants resident in rural areas (88.7) do not know or have a testing site and none had ever been confirmed positive for COVID-19 with a great statistically significant difference.On the other hand, we observed neither a striking difference nor an association on whether the participants Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected...The level of public awareness on COVID-19 was also evaluated in relation to some demographic parameters (sex, area of residence, level of education and occupation) (Table 7).We observed a great association between level of awareness and area of residence as relatively fewer persons in rural areas were aware, same with level of education as much fewer uneducated persons demonstrated awareness, likewise with occupation as students, farmers and other persons in the informal sector of work showed lesser awareness towards the COVID-19 pandemic.

ASSOCIATION BETWEEN COVID-19 AWARENESS AND OTHER VARIABLES
Table 8 also illustrates the participants' level of awareness to COVID-19 with respect to other variables.Our findings confirmed a statistically significant association between whether the participants will readily go for testing, knew / had testing sites and were prevented from testing by the conflict situation in relation to their level of awareness to COVID-19.

DISCUSSION
Since the outbreak of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causing the Coronavirus disease 2019 (COVID-19), 2 key elements to adequately controlling the virus remains public awareness towards the mode of spread, signs/symptoms and method of prevention. 12This study accessed the level of awareness of residents within the two conflict affected Anglophone regions of Cameroon and found that a great majority of the participants had heard of the disease, mostly through the social media, but could not correctly identify the modes of transmission, signs and symptoms or the methods of prevention.We previously reported higher results from the inhabitants of Bamenda city, Regional capital of the North West. 13The high level of awareness of the disease contrasted by lower levels of awareness on the mode of spread, signs/symptoms and method of prevention could be due to social media being the main source of information to the participants.Social media remains an untrusted source of information especially regarding the COVID-19 pandemic as there exist different theories on the origin, mode of containment and treatment of the virus on these platforms.This might have accounted for misinformation on COVID-19 and incorrect identification of the transmission and prevention methods (Table 2).This could be justified by the fact that, almost a third of the participants belief COVID-19 is either a man-made biological weapon, an exaggeration by news media or government to cause panic or a plague caused by sins of man (Table 2).Our findings cor-  roborate with Cinelli et al., 14 who recognised the power of social media in misinforming the public on COVID-19.Also, despite numerous management/treatment options for the virus, 60% of the participants said it does not exist and with just 7% being able to identify the treatment option being used by the Cameroon government. 15Associating participant's level of public awareness on COVID-19 with some demographic parameters (Table 7), showed a great association, indicating where one resides, level of education and occupation were significant determinants.This can be explained by the fact that the mainstream media (Cameroon Radio Television) which is the portal through Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected...This study also provides valuable information on the health seeking practices of the residents of the North West and South West Regions during and towards the COVID-19 pandemic.This was of great importance considering the level of stigmatisation faced by COVID-19 patients and the high rate of suspicion among residents on the origin and management of the Coronavirus 2019.Interestingly, a majority of the participants still preferred government hospitals (33%) of the different options, though a significant proportion (26.8%) practised self-medication.To mitigate the impact from self-medication during COVID-19 pandemic, it is worth looking into IPC solutions that work for Cameroon emphasized by Boum et al. 3 Unfortunately, only two of the 20 participants who had either tested positive (8) or suspected positive (12) for COVID-19 had been to the different treatment centres set up by the government while a majority of those who had experienced COVID-19 related symptoms preferred self-medication.This is of great concern as most people with mild Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected... COVID-19 symptoms often roll out the possibility of having the real epidemiological situation of COVID-19 infection in Cameroon due to the heightened level of disbelief on the existence of the virus among the population.These group who might be truly COVID-19 positive, risk transmitting the virus as they evade proper containment measures including self-isolation, quarantine and contact tracing.

Journal of Global Health Economics and Policy
The level of COVID-19 testing by participants was also a focus of this study.In the absence of a licenced treatment and with vaccine administration, still a far reality in Cameroon, testing remains one of the main means of controlling the spread of the virus and getting back to normalcy.The real-time reverse transcriptase polymerase chain reaction (RT-PCR) to detect human SARS-CoV-2 RNA in nasopharyngeal cells collected through a nasal swab remains the goal standard in COVID-19 diagnosis. 2,16,17This unfortunately is only available in the Regional headquarters of Bamenda and Buea with little capacity to match the skyrocketing rate of infections.With the recent availability of rapid diagnostic test to identify SARS-CoV-2 antigen in a nasal swab though with low sensitivity, 2,18 the government has been able to decentralise testing to district levels with promising results.Our findings revealed that while 61.2% of the participants are willing to go for a COVID-19 test (Table 4), only 32.6% knew a sample collection or testing site.This raises questions as to what has been done to sensitize communities on where they could access COVID-19 testing if presenting with symptoms.This, especially as we observed a significant association between participants who had been tested and their area of residents, with none from residents in the rural areas ever testing positive for COVID-19.
Although the Cameroon Ministry of Public Health has increased testing capacity to involve testing within districts following the Trace, Test and Track approach 2 up to 28% of respondents in conflict settings will still have to cover long distances to perform a COVID-19 test.This call for more decentralisation of testing sites within conflict settings especially considering 25% cannot access testing sites for fear of gunshots, kidnapping or ghost towns.The COVID-19 test is offered free at testing sites, yet 69% of respondents are not aware of this.This may account for low prevalence of subjects who have been tested for COVID-19 despite numerous ones who presented with symptoms.This could be due to the level of education, occupation and residence of the participants.

CONCLUSIONS
We believe this study presents the first findings on barriers to COVID-19 testing in conflict-affected settings more precisely in Cameroon.Our study observed that despite being aware of the existence of COVID-19 mostly through the social media, most of the participants lacked adequate knowledge on the mode of transmission, signs and symptoms and on the methods of prevention of the disease.On the health seeking practices of participants, we observed that a majority still practised self-medication avoiding testing and government treatment centres despite having experience signs/symptoms related to COVID-19.Also, a majority of participants who did not go for testing did not know or have a sample collection site in their area of residence while some who were willing had to travel long distances before getting to a testing site.Finally, the armed conflict in the North West and South West prevented a quarter of participants from getting testing as they were either scared of gunshots, being kidnapped or the effects of ghost towns.
We recommend the use of social media by the Ministry of Public Health, civil society organisations and researchers to pass out correct information on COVID-19.Training of community health workers, religious and traditional leaders in sensitization on COVID-19 in conflict settings to demystify theories on COVID-19 is recommended.Also, additional creation of more testing sites within communities including the use of humanitarian health organizations in reaching the hard-to-reach conflict areas is encouraged.Lastly, further studies on COVID-19 testing uptake within districts are recommended.

Table 1 . Socio-demographic data
With regards to their awareness of the different treatment options, only about a third (39.7%) of the participants knew COVID-19 could be treated (managed) but with less than 20% being able to state any treatment or management option including Ash Bishop Kleda's herbal tea, (2.1%), use of Chloroquine and Azithromycin (7.3%), assorted use of herbs and fruits (8.3%) and drinking/inhaling of warm water (1.8%).On whether a vaccine existed, only 14.9% of the Public awareness, health seeking practices and constraints to uptake of COVID-19 testing in the conflict-affected...HEALTH SEEKING PRACTICES RELATED TO COVID-19

Table 3 . Health seeking practices related to COVID-19
ASSOCIATION BETWEEN PARTICIPANTS' AREA OF RESIDENCE AND COVID-19 VARIABLES

Table 4 . Uptake of COVID-19 testing
*NA -not applicable; *ID -identity Card will readily go for COVID-19 testing if they had symptoms, if they had or knew testing sites or if living in a conflict setting prevented them from getting tested.ASSOCIATION BETWEEN COVID-19 AWARENESS AND DEMOGRAPHICS