Theoretical framework

Herzlich’s theory of social representations of health and illness was used to frame this study. Social representation of health and disease is a concept introduced by Herzlich in 1973 and has been presented in more recent research to understand the relationship between social representations of health and health behaviors. Social representations of health and illness significantly impact individual and collective health behaviors and have been highlighted as an area in which further research is needed [19]. According to Herzlich (1973), social understandings of influence the way individuals perceive and interpret symptoms, seek medical care, adhere to treatment, and engage in health-promoting behaviors [20]. Therefore, understanding these social representations is crucial for promoting health and designing effective health interventions. Herzlich’s theory of social representations of health and illness was selected in alignment with the use of qualitative inquiry to explore the perceptions and knowledge of COVID-19 among individuals in the communities in Cameroon.

Design

In this qualitative study, we used a comprehensive and deductive research design to understand perceptions of COVID-19. Deductive qualitative research involves the “top-down” approach to data analysis by developing of predetermined codes [20]. We selected a deductive approach to support the organization of the data into categories in alignment with the research questions.

We used individual semi-structured interviews and focus group discussions (FGDs), where individual interviews were to explore personal experiences, and FGDs were to examine opinions and beliefs about the subject matter. Interviews and focus groups are the most used data collection methods in qualitative research as they allow for exploring the views, experiences, beliefs, and motivations of study participants [21]. Focus groups allow participants’ experiences to be explored in an interactive setting. To account for both the individual and group dynamics, we collected both interview and focus group data, which were analyzed together to improve the validity and reliability of the results [22].

Participants

In line with good practice for qualitative studies [23], purposive sampling was used to select study participants. The target was a heterogeneous sample of participants who had been in contact with or had experience with COVID-19, in health centers, households, and the community. This sampling approach allowed for the recruitment of five different social and demographic categories to exploit a wide range of perceptions of the disease at the level of the various strata of society. A total of 25 participants were recruited from five categories: health personnel, patients (with a confirmed COVID-19 infection), contact persons (had been in close contact with a confirmed COVID-19 infected individual), community members, and community leaders (Table 1). All participants took part in the focus groups and were also interviewed. Selected participants were also diversified in terms of their ages and gender. We considered a community leader as a man or woman who was identified by others in the community as someone who is looked up to as a head of an organized group, one who is opinion is widely respected or is known for enabling others to act [24].

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Table 1. Organization of interviews.

https://doi.org/10.1371/journal.pgph.0001760.t001

Data collection

The field visits were preceded by developing a semi-structured interview guide with themes that emerged from previous literature reviews and consultation with a social science subject matter expert. Participants were identified and recruited from private health centers, household, and community visits to participate in the study. A total of 25 participants took part in the study and were interviewed by two research team members: a research assistant and a social scientist. Each interview lasted an average of 30 minutes. Two FGDs were conducted with eight (8) participants in two cities with the highest incidence of COVID-19 in Cameroon (Douala and Yaoundé) for approximately two hours each. The recorded audio files were transcribed in Word format by the research team. A codebook containing a catalog of themes developed from the interviews and FGDs guides was prepared in advance to facilitate coding by referring to some coding manuals [20, 21, 25]. Data coding was performed manually directly on the verbatim in a collaborative manner by the team: The work was organized in a team of 3 three people coding each transcript individually on a shared online document. The coding was then reviewed and harmonized during a workshop with additional research team members (5 people) that revised and finalized the coding.

Data analysis

After transcription, five independent coders conducted data analysis through several iterative rounds of coding. A consensus of three of five coders was used in establishing the codes and themes. Codes and themes that did not meet this consensus were revised or removed from the final coding scheme. A cycled coding approach was used as suggested by Saldaña for theme development [25]. The cycled coding approach involved seven phases. In the first phase, exploratory coding was conducted independently by each individual coder. This initial data coding was performed through line-by-line manual of the text of the transcripts. Each member of the team involved in the coding highlighted the answers of the interviewee: the theme, the number of the corresponding code, highlighting the relevant quote, and adding one or more observations if necessary. The exploratory coding was intended to identify initial patterns within the data, corresponding with the research question. In the second phase, the results of the independent coding were discussed, supported by memos justifying the initial codes identified by each researcher. The initial codes were discussed and revised until consensus on interpretation was reached. In the third phase, the codes were organized into categories through code grouping. The codes’ organization was based on patterned coding as a cycle of coding in the data analysis process. A coding scheme was then developed based on the grouping and categorization of the codes. In the fourth phase, the categories were reviewed in connection with the research questions, using a focused coding approach. This phase involved revising code groups and supporting quotations from the data collected. After the code groups were developed, the fifth phase involved the development of a codebook based on the established code groups. Descriptions of the themes and subthemes were developed as part of developing the codebook, through discussion among the five coders. Examples of each theme and subtheme were also identified using participants’ quotes extracted from the transcripts. The codebook developed is presented in Table 2 supported by the codebook. The sixth phase involved identifying points of saturation of each theme and subtheme, which was established based on participant consensus of at least 80% for the main themes (n = 20), at least 50% for themes (n = 13), and at least 30% for subthemes (n = 8). In the seventh and final phase, the researchers reflected on the themes and concepts in alignment with the data, research questions, and theory. Based on these reflections, the presentation of results and discussion sections were developed, as presented below.

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Table 2. Codebook from cycled coding including theme and subtheme saturation.

https://doi.org/10.1371/journal.pgph.0001760.t002

Rigor

Multiple working sessions were organized to discuss the themes and concepts identified from the rounds of coding. Multiple coders were utilized to support the validity of the identified themes. The team consisted of five researchers, including a social science research expert. As described above, the first level of analysis was performed independently by each researcher during their interviews; then, meetings were held to harmonize the categories and themes to be retained. Results were discussed until consensus on interpretation was reached. Subsequently, the codebook was revised based on the themes found in the first data collected.

Ethical consideration

Participation in this study was voluntary. Participants were only enrolled after signing a written informed consent form.

Confidentiality was maintained by anonymizing the participant’s identity and data.

This study was approved by the National Ethics Committee of Cameroon (No. 202/07/1265/CE/CNERSH/SP).

Theme 1: Beliefs about general knowledge of COVID-19

This first theme highlights how the participants described COVID-19, depending on their experience. Generally, respondents provided a variety of opinions relating to their knowledge of this novel infection, ranging from where the disease originated, a clear definition of the infection and how it can be contracted and its main signs and symptoms, and sharing their doubts concerning whether the virus existed. Patients and their contacts seemed to be well-informed about the origin of the disease, and they had accurate information and knowledge of the COVID-19 infection and its symptoms. However, some of them were still doubtful of the virus’s existence and believed the disease was a made up as a hoax.

“It’s a virus that appeared already about ten years ago, and its current version COVID-19 was first diagnosed in I think November or October 2019 in China. But before that, there was also SARS-1 which was also other forms of COVID.”

(Interview Patient contact, Male)

However, some respondents sometimes manifested doubts and tended to minimize the disease.

“Mentally, I perceived this disease as a utopia; it is often said that when misfortune is not next to you, you will find it difficult to consider it. At first, I was informed that COVID exists, then I was reassured because although I had been close to the patient, I tested negative for the disease. So that increased my faith, and I still have it, because if I give you my personal experience of the flu in question, I confess that my body has the capacity to resist the flu.”

(Focus group patient contact, male).

On the other hand, community leaders and members presented the disease according to information they received in the community or the media. Sometimes, they are mainly influenced by what information is obtained and behaviors they observe in their community.

“According to the information that we have on radio, television and in the newspapers, the Coronavirus is a disease that comes from China. That’s what they made us understand.”

(Focus group Community leader, female)

Although healthcare worker participants had no prior training and exposure related to the COVID-19 infection, they had a good understanding of the disease and were knowledgeable about the origin, signs, and symptoms as well as the transmission and prevention methods against the infection.

“What I know about corona viruses is that they are found in animals, and they infect humans… Yes, there are many types that have occurred just like the SARS. So, this one COVID-19 it is just known, to be originating from bats and its infecting humans”

(Focus group Health Care Worker, female)

Theme 2: Barrier measures of COVID-19

We distinguished between two types of barrier measures: individual protection measures (wearing a mask, washing hands, social distancing); and those imposed on individuals that are more collective measures (curfew, hand washing stations, systematic temperature measurement, limitation of gatherings). Generally, all participants claimed to try to observe the barrier measures, particularly mask-wearing and handwashing. However, some respondents also talked about protective practices in addition to those prescribed by authorities. Concerning the individual protection measures observed by the respondents, health personnel accustomed to wearing a mask as part of their profession quickly complied with the individual protection measures as deemed relevant to protect themselves from the pandemic:

“What has changed is the wearing of masks that is now universal. And it’s true that before, in the hospital masks were mandatory in some instances, the operating theatre, but not everybody.. It has changed a lot because everyone wears a mask.”

(Interview Health Care Worker, female).

Non-health care professional participants also complied with the respect of barrier measures:

“Personally, to protect myself from the coronavirus, I always wear a mask, whenever I go out and come back home, I wash my hands, I try to wash my face with soap as well. And when I’m in public, I try to be able to maintain the barrier measures as prescribed.”

(Interview Patient contact, male).

“I avoid people as much as possible, I avoid crowds, I wear my mask whenever I go out and I respect the one-meter distance; I think that’s what I’ve been told.”

(Interview Community member, female).

Regarding collective protection measures, participants pointed out protective measures taken either at the level of their workplace, or at the level of public services and public places such as churches, supermarkets, etc.

“There’s temperature taking, which wasn’t done before at the official buildings, hand washing points everywhere. Yes, there are rooms that have been reserved just to put a patient there because it’s reserved for suspected cases of COVID-19.”

(Focus group Health Care Worker, female).

Participants also mentioned using some protective measures that were not government mandated:

“I always wear my mask. When I come home at night, I make my tea with mint crystals which I drink every day before going to sleep and in the morning before going out. I buy these mint crystals every three days.”

(Interview Community leader, male).

Theme 3: Impact of the disease

Participants described that the COVID-19 pandemic significantly impacted people’s daily life at several levels. This impact is more pronounced on social changes imposed on the community’s daily habits and lifestyle, including restricted social interactions and human relationships. In addition, participants mentioned the impact on their professional lives. The pandemic’s impact on the economy was mentioned regarding the slowdown of economic activities and profitability. For example, health personnel reported lower attendance at health facilities, resulting in reduced revenues. Community members mainly expressed concern about the lack of purchasing power and increased unemployment.

“The main challenge we faced was the population that reduced in the hospital because of fear and payment difficulties.”

(Interview Health Care Worker, male)

“Yes, for example, prices have increased on the market as you can see. Even with a sum of 5,000 CFA francs it is not enough to shop and cook for a one-day meal for everyone in the house”

(Interview Community Member, female)

Sometimes, health personnel reported their experiences in terms of fear of contagion from others, once back home.

“It’s true that I haven’t lost anyone, a family member to the coronavirus yet, but when I see others die at work, I am also upset. Otherwise, we are still living in fear that it can kill us, it could…”

(Focus group Health Care Worker, male)

Some Health workers mentioned trust in medicine, considering COVID-19 as a disease like any other that can be cured if measures are taken. However, many others have experienced these various changes from the perspective of strict compliance with a set of measures in the hospital environment.

“It’s just that we’ve had an increase in personal protective equipment. All the staff, everyone with their own equipment, aprons, everything; glasses, gloves. Everyone had this and it is true that at the beginning, the patients had decreased a little but afterwards it returned to normal”

(Focus group Health Care Worker, male)

Social and family changes

Many respondents reported that the pandemic had impacted their social relationships and interactions with others and contributed to “cutting the social link” with loved ones (family members, friends, and community members). This perception is widely shared by contact persons, patients, community members, and leaders.

“Automatically our community is affected because it is not as close as it used to be. We no longer have this possibility of being able to deal directly family about certain things.”

(Interview Patient contact, female)

Knowledge of COVID-19: Antagonism between real disease and invention

For some of our study participants, the disease was non-existent or exaggerated, the effects of which were amplified by the dominant culture (Governments, local authorities, media, and international community). This perception highlights the suspicions around the disease’s origin, the ambiguities on the treatment, and other conspiracy theories found in the media. Some participants who became ill and were confirmed to be infected with COVID-19 expressed rejection of their illness in the face of what they deemed a trivial sickness. In some instances, our study respondents also found information (found in the media or disseminated by the government) about COVID-19 to be vague and not explicit enough. For some participants, this acquired information was sometimes contradictory to their lived experiences during the pandemic. Several studies have documented the popular perception of SARS-CoV2 emerging from genetic manipulation from a laboratory in China [28, 29]. Our results show communities in Cameroon learning from their lived experiences what the scientific community would take longer to confirm: For multiple still-contested reasons, much of Africa was less susceptible to a high burden of disease from COVID-19 than many other parts of the world.

Barrier measures imposed by the “dominant culture”

Although our study participants reported observing personal and collective protective measures and to avoid infection, many believed that the facts or information relayed by the media, the national government, and the international health authorities was exaggerated. However, given the strict measures adopted and the expected punishments, our participants felt obligated to respect the barrier measures and the directives imposed by the government, in part due to the evidentiary charisma of projections and responsive government decisions. It has even been argued that the COVID-19 pandemic could be perceived as a “Revolution” [14] where the impact of COVID-19 is perceived not only as a disease but a new world order. In other ways, the pandemic can be seen as a social phenomenon that imposes itself on everyone and modifies the way of life on several levels. In a study conducted in the Democratic Republic of Congo, adherence to preventive measures against COVID-19 was found to be suboptimal, despite the compulsory guidelines instituted by the DRC government [13]. Lack of adherence to government-mandated guidelines was blamed on the government’s lack of effort in community engagement. In Cameroon, the dissonance between the official news and the imposition of control measures shows the potential for social learning to undermine government and other power structures when communities’ experiences are in tension with perceived overreactions to disease outbreaks. This incongruity has implications for how scientists inform governments with evidence and how governments use evidence to make decisions in disease response that impinge on communities whose experiences do not align with the original evidence.

Impact of the disease

According to our study participants, the COVID-19 pandemic has imposed new regulations on social habits and human relationships. Due to its perceived global severity, this health emergency had a profound impact on society, forcing populations all around the world to modify daily habits (social distancing) as well as adopt new ones (confinement), which led to a sort of rupture of social activities and the social life as they knew it. Many of our study participants also reported experiencing a lack of trust in public health institutions which has been corroborated by various studies in other contexts [22, 23, 30]. Therefore, our study participants believed in not having a choice but to learn how to live with this pandemic, integrate the new habits, accept the virus with its multitude of mutations, and accept being vaccinated against it. Initial determination to comply with restrictions and resilience to deal with the economic and social costs gave way to confusion, doubt, and frustration about the intentions of institutions like the government, health research and global health security apparatus whose actions and advice felt out of step with communities’ experiences. When the evidence on the lower burden of disease of COVID-19 in Africa began to change, messaging and restrictions did not change to match, and this expanded the social learning space for conspiracy theories, doubt, and misinformation to explain the gap between the social representation communities were constructing of the threat of COVID-19 in and the one public health officials at multiple levels were communicating. This contrast flags a potential danger of risk communication attempts to exaggerate the threats of a disease to secure compliance with public health measures.

Decrease in economic activities

Our study participants also noted the decrease in economic activities as a significant negative impact on people’s daily life, as some had lost their jobs or private businesses during this period. Moreover, the impact of this health emergency on African economies has been widely documented. The African Development Bank estimates that economic growth in the continent shrank by 2.1% in 2020 [31]. Also, a previous analysis on the impact of the COVID-19 pandemic on employment in Cameroon found that 60.93% suffered a wage cut while 31.16% faced job suspension, and 7.37% experienced job loss [32].

Although study participants accepted the pandemic regardless of, in some instances, the lack of synchronicity with their personal experience, they admitted to being compelled to endure its impact on their daily lives and their economic activities. Communities’ understandings of the hardship and suffering associated with the economic impact of health restrictions were in tension with the severity of disease that supposedly justified those restrictions. The conceptions of COVID-19 among communities in Cameroon shifted from a threat that requires action that inspired compliance and even stewardship of health measures to a non-serious threat that needs revision that inspired doubts and undermined the legitimacy of expensive, coercive public health restrictions and the institutions that advocated for them.

Limitations

The study was carried out in urban areas in two large cities with the highest COVID19 infection rates in Cameroon, and the findings may not apply to rural areas that were less affected. Beliefs and habits in rural communities in Cameroon may be influenced by other exogenous or endogenous factors such as influential members of the community, rites, and ancestral traditions, consumption habits, among others. As interviews and focus group discussions were conducted, recorded, and transcribed in French, the translation process may have obscured the nuances of the original recordings. Despite bilingualism and professional and personal experience with Cameroonian communities, researchers’ overlap in the collection and analysis of the data may introduce some bias. Questions asked during the interviews and focus group discussions may have covered only some aspects of the health crisis.