Illness experiences and mental health challenges associated with female genital schistosomiasis in Cameroon: a gender analysis

Background: This paper highlights the role of cultural and structural gaps that shape illness experiences of women with manifestations of female genital schistosomiasis (FGS) and their impacts upon mental well-being. Methods: Using ethnography, case study narrative accounts of women manifesting symptoms of FGS, as well as interviews with health workers within FGS-endemic rural fishing communities in Cameroon, we present experiences of women affected by FGS, alongside information on FGS health service provision. Results: Our results show how gendered power dynamics in decision making, gendered experiences around menstrual health and structural gaps in service provision, combine and lead to poor mental well-being. Subfertility brings a heavy psychosocial toll from external blame and rejection, exacerbated by internalised stigma and the challenge of not being able to fulfil cultural and gendered social norms. Conclusions: Gender analysis is key to developing context-embedded understanding and addressing FGS-related challenges. With context-specific experiences demonstrating FGS comorbidity with mental ill health, there is a need to prioritise mental health integration at policy level through a person-centred approach. Furthermore, to address stigma and discrimination, campaigns to raise awareness in Cameroon, and beyond, are needed. Contexte: Cet article met en évidence le rôle des lacunes culturelles et structurelles qui façonnent les expériences des femmes atteintes de schistosomiase génitale féminine (SGF) et leur impact sur le bien-être mental. La méthode: À l'aide de l'ethnographie, de récits d'études de cas de femmes présentant des symptômes de schistosomiase génitale féminine, et d'entretiens avec des agents de santé au sein de communautés de pêcheurs ruraux endémiques de la schistosomiase génitale féminine au Cameroun, nous présentons les expériences des femmes touchées par le SGF, ainsi que des informations sur les services de santé liés au SGF. Résultats: Nos résultats montrent comment la dynamique du pouvoir dans la prise de décision, les expériences de la santé menstruelle et les lacunes structurelles dans la fourniture de services, interagissent et conduisent à un manque de bien-être psychologique. La sous-fécondité entraîne un lourd fardeau psychosocial du fait du blâme et de rejet externes auxquelles sont assujetties les personnes souffrant de la maladie, ce qui est exacerbé par la stigmatisation intériorisée et le défi que représente leur incapacité à respecter les normes sociales culturelles et sexospécifiques. Conclusion: L'analyse de genre est essentielle pour développer une compréhension intégrée au contexte et pour relever les défis liés aux SGF. les défis liés à l'ESF. Avec des expériences spécifiques au contexte démontrant la comorbidité de la FGS avec la mauvaise santé mentale, il est nécessaire de donner la priorité à l'intégration de la santé mentale au niveau politique par le biais d'une approche centrée sur la personne. l'intégration de la santé mentale au niveau politique par une approche centrée sur la personne. En outre, pour lutter contre la stigmatisation et la stigmatisation et la discrimination, des campagnes de sensibilisation sont nécessaires au Cameroun et au-delà. Antecedentes: En este documento se pone de relieve el papel de las brechas culturales y estructurales que dan forma a las experiencias de enfermedad de las mujeres con manifestaciones de Esquistosomiasis Genital Femenina (EGF), y sus impactos en el bienestar mental. Método: Utilizando la etnografía, estudios de caso mediante relatos narrativos de mujeres que manifiestan síntomas de EGF y entrevistas con trabajadores sanitarios de comunidades pesqueras rurales endémicas en Camerún, presentamos las experiencias de las mujeres afectadas por la EGF, junto con información sobre la prestación de servicios sanitarios para la EGF. Resultados: Nuestros resultados muestran cómo la dinámica de poder de género en la toma de decisiones, las experiencias de género en torno a la salud menstrual y las deficiencias estructurales en la prestación de servicios se combinan y conducen a un bienestar mental deficiente. La subfertilidad conlleva un alto coste psicosocial debido a la culpa y el rechazo externos, exacerbados por el estigma interiorizado y el reto de no poder cumplir las normas culturales y de género. Conclusión: El análisis de género es clave para desarrollar una comprensión integrada en el contexto y abordarlos retos relacionados con la EGF. Dado que las experiencias específicas de cada contexto demuestran la comorbilidad de las EGF con la enfermedad mental, es necesario priorizar la integración de la salud mental en las políticas a través de un enfoque centrado en la persona. Además, para hacer frente al estigma y la discriminación, son necesarias campañas de sensibilización en Camerún y en otros lugares

Urogenital schistosomiasis (UGS) and female genital schistosomiasis (FGS) in Cameroon: an observational assessment of key reproductive health determinants of girls and women in the Matta Health Area

Objectives and setting: Across sub-Saharan Africa, urogenital schistosomiasis (UGS), in particular female genital schistosomiasis (FGS), is a significant waterborne parasitic disease, with its direct burden on the sexual and reproductive health (SRH) of sufferers infrequently measured. UGS has an established control plan, which in most endemic regions as in Cameroon, still excludes FGS considerations. Highlighting existent associations between UGS and FGS could increase the management of FGS within UGS interventions. This study seeks to identify current associations among FGS and UGS with some reproductive health indicators, to provide formative information for better integrated control. Participants: 304 females aged 5–69 years were all examined for UGS by urine filtration and microscopy. Among these, 193 women and girls were eligible for clinical FGS assessment based on age (>13). After selective questioning for FGS symptoms, a subgroup of 67 women and girls consented for clinical examination for FGS using portable colposcopy, with observed sequelae classified according to the WHO FGS pocket atlas. Outcome: Overall UGS and FGS prevalence was measured, with FGS-related/UGS-related reproductive health symptoms recorded. Associations between FGS and UGS were investigated by univariate and multivariate logistic regression analyses. Results: Overall UGS prevalence was 63.8% (194/304), where FGS prevalence (subgroup) was 50.7% (34/67). FGS manifestation increased significantly with increasing age, while a significant decrease with ascending age was observed for UGS. Lower abdominal pain (LAP) vaginal itches (VI) and coital pain (CP) were identified as the main significant shared symptoms of both FGS and UGS, while LAP with menstrual irregularity (MI) appeared a strong symptomatic indicator for FGS. Conclusion: LAP, MI, CP and VI are the potential SRH indicators that could be exploited in future for targeting of praziquantel provision to FGS sufferers within primary care, complementary with existing praziquantel distribution for UGS sufferers in Schistosoma haematobium endemic areas

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities

Background Female Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey. Method A cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews. Result Amongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6–28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8–70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch. Conclusion With our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women’s health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level

Achieving equity in UHC interventions: who is left behind by neglected tropical disease programmes in Cameroon?

Background: The UN’s Sustainable Development Goals (SDGs) which pledge to leave no one behind for Universal health coverage (UHC) raise the importance of ensuring equitable health outcomes and healthcare delivery. As Neglected Tropical Diseases (NTDs) affect the most disadvantaged and hard to reach populations, they are considered a litmus test for Universal health coverage. Objective: Here, we assess the challenges of implementing Mass Drug Administrations (MDAs) for schistosomiasis prevention and control, in a context of expanded treatment where both community and school-based distribution were carried out, assessing which groups are missed and developing strategies to enhance equity. Methods: This is a qualitative study applying ethnographic observations, in-depth interviews (109) and focus group discussions (6) with key informants and other community members. Participants included community drug distributors, teachers, health workers, and implementing partners across four schistosomiasis endemic regions in Cameroon. Data collected were analysed thematically. Results: Programme implementation gaps have created circumstances where indigenous farmers (originally from the region) and migrating farmers (not originally from the region known as ‘strangers’ and ‘farm hands’), women of reproductive age and school-aged children are continuously missed in MDA efforts in Cameroon. Key implementation challenges that limit access to MDA within this context include inadequate sensitization campaigns that don’t sufficiently build trust with different groups; limits in CDD training around pregnancy and reproductive health; lack of alignment between distribution and community availability and the exclusion of existing formal and informal governance structures that have established trusting community relationships. Conclusion: Through identifying key populations missed in MDAs within specific contexts, we highlight how social inclusion and equity could be increased within the Cameroonian context. A main recommendation is to strengthen trust at the community level and work with established partnerships and local governance structures that can support sustainable solutions for more equitable MDA campaigns

Neglected Tropical Diseases as a ‘litmus test’ for Universal Health Coverage? Understanding who is left behind and why in Mass Drug Administration: Lessons from four country contexts

Individuals and communities affected by NTDs are often the poorest and most marginalised; ensuring a gender and equity lens is centre stage will be critical for the NTD community to reach elimination goals and inform Universal Health Coverage (UHC). NTDs amenable to preventive chemotherapy have been described as a ‘litmus test’ for UHC due to the high mass drug administration (MDA) coverage rates needed to be effective and their model of community engagement. However, until now highly aggregated coverage data may have masked inequities in availability, accessibility and acceptability of medicines, slowing down the equitable achievement of elimination goals

Female Genital Schistosomiasis (FGS) in Cameroon: A formative epidemiological and socioeconomic investigation in eleven rural fishing communities.

BackgroundFemale Genital Schistosomiasis (FGS) is most often caused by presence of Schistosoma haematobium eggs lodged in the female reproductive tract which results in chronic fibrosis and scarring. In Cameroon, despite high community prevalences of urine-patent S. haematobium infections, FGS has yet to be studied in depth. To shed light on the clinical prevalence and socioeconomic effects of FGS, we undertook a formative community-based epidemiological and qualitative survey.MethodA cross sectional multidisciplinary study of 304 girls and women from 11 remote rural fishing communities in Cameroon was undertaken using parasitological sampling, clinical colposcopy, and interviews. The lived experiences of those with FGS were documented using a process of ethnography with participant observation and in-depth interviews.ResultAmongst 304 women and girls aged >5 years (Median age: 18; Interquartile range: 9.6-28), 198 females were eligible for FGS testing and 58 adult women were examined by clinical colposcopy. Of these, 34 were positive for FGS (proportion: 58.6%; 95% CI: 45.8-70.4), younger girls showing a higher FGS prevalence, and older women not shedding eggs showing a pattern for cervical lesions from earlier infection. In a subset of women with FGS selected purposively (12/58), in-depth interviews with participant observation revealed out-of-pocket expenditures of up to 500USD related health spending for repeated diagnosis and treatment of gynecological illnesses, and 9 hours daily lost reproductive labour. Psychosocial unrest, loss in social capital, and despair were linked with sub-fertility and persistent vaginal itch.ConclusionWith our first formative evidence on prevalence, socioeconomic effects and experiences of FGS amongst women and girls in Cameroon, we have clarified to a new level of detail the deficit in provision of and access to peripheral health services in remote areas of Cameroon. Using this information, there is now strong evidence for national programs and services on women's health and schistosomiasis to update and revise policies targeted on prevention and management of FGS. We therefore stress the need for regular provision of Praziquantel treatment to adolescent girls and women in S. haematobium endemic areas, alongside better access to tailored diagnostic services that can detect FGS and appropriately triage care at primary health level

Safety and immunogenicity of seven COVID-19 vaccines as a third dose (booster) following two doses of ChAdOx1 nCov-19 or BNT162b2 in the UK (COV-BOOST): a blinded, multicentre, randomised, controlled, phase 2 trial

Background: Few data exist on the comparative safety and immunogenicity of different COVID-19 vaccines given as a third (booster) dose. To generate data to optimise selection of booster vaccines, we investigated the reactogenicity and immunogenicity of seven different COVID-19 vaccines as a third dose after two doses of ChAdOx1 nCov-19 (Oxford–AstraZeneca; hereafter referred to as ChAd) or BNT162b2 (Pfizer–BioNtech, hearafter referred to as BNT). Methods: COV-BOOST is a multicentre, randomised, controlled, phase 2 trial of third dose booster vaccination against COVID-19. Participants were aged older than 30 years, and were at least 70 days post two doses of ChAd or at least 84 days post two doses of BNT primary COVID-19 immunisation course, with no history of laboratory-confirmed SARS-CoV-2 infection. 18 sites were split into three groups (A, B, and C). Within each site group (A, B, or C), participants were randomly assigned to an experimental vaccine or control. Group A received NVX-CoV2373 (Novavax; hereafter referred to as NVX), a half dose of NVX, ChAd, or quadrivalent meningococcal conjugate vaccine (MenACWY) control (1:1:1:1). Group B received BNT, VLA2001 (Valneva; hereafter referred to as VLA), a half dose of VLA, Ad26.COV2.S (Janssen; hereafter referred to as Ad26) or MenACWY (1:1:1:1:1). Group C received mRNA1273 (Moderna; hereafter referred to as m1273), CVnCov (CureVac; hereafter referred to as CVn), a half dose of BNT, or MenACWY (1:1:1:1). Participants and all investigatory staff were blinded to treatment allocation. Coprimary outcomes were safety and reactogenicity and immunogenicity of anti-spike IgG measured by ELISA. The primary analysis for immunogenicity was on a modified intention-to-treat basis; safety and reactogenicity were assessed in the intention-to-treat population. Secondary outcomes included assessment of viral neutralisation and cellular responses. This trial is registered with ISRCTN, number 73765130. Findings: Between June 1 and June 30, 2021, 3498 people were screened. 2878 participants met eligibility criteria and received COVID-19 vaccine or control. The median ages of ChAd/ChAd-primed participants were 53 years (IQR 44–61) in the younger age group and 76 years (73–78) in the older age group. In the BNT/BNT-primed participants, the median ages were 51 years (41–59) in the younger age group and 78 years (75–82) in the older age group. In the ChAd/ChAD-primed group, 676 (46·7%) participants were female and 1380 (95·4%) were White, and in the BNT/BNT-primed group 770 (53·6%) participants were female and 1321 (91·9%) were White. Three vaccines showed overall increased reactogenicity: m1273 after ChAd/ChAd or BNT/BNT; and ChAd and Ad26 after BNT/BNT. For ChAd/ChAd-primed individuals, spike IgG geometric mean ratios (GMRs) between study vaccines and controls ranged from 1·8 (99% CI 1·5–2·3) in the half VLA group to 32·3 (24·8–42·0) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·1 (95% CI 0·7–1·6) for ChAd to 3·6 (2·4–5·5) for m1273. For BNT/BNT-primed individuals, spike IgG GMRs ranged from 1·3 (99% CI 1·0–1·5) in the half VLA group to 11·5 (9·4–14·1) in the m1273 group. GMRs for wild-type cellular responses compared with controls ranged from 1·0 (95% CI 0·7–1·6) for half VLA to 4·7 (3·1–7·1) for m1273. The results were similar between those aged 30–69 years and those aged 70 years and older. Fatigue and pain were the most common solicited local and systemic adverse events, experienced more in people aged 30–69 years than those aged 70 years or older. Serious adverse events were uncommon, similar in active vaccine and control groups. In total, there were 24 serious adverse events: five in the control group (two in control group A, three in control group B, and zero in control group C), two in Ad26, five in VLA, one in VLA-half, one in BNT, two in BNT-half, two in ChAd, one in CVn, two in NVX, two in NVX-half, and one in m1273. Interpretation: All study vaccines boosted antibody and neutralising responses after ChAd/ChAd initial course and all except one after BNT/BNT, with no safety concerns. Substantial differences in humoral and cellular responses, and vaccine availability will influence policy choices for booster vaccination. Funding: UK Vaccine Taskforce and National Institute for Health Research