Why does Malaria Persist despite Control Interventions in Cameroon? A Multi-stakeholder Qualitative Study using the Social Ecological Model

Abstract Introduction Despite decades of malaria control interventions, malaria remains a major public challenge in Cameroon. Our study explored stakeholder perceptions of the factors contributing to the persistence of malaria in Cameroon using the Social Ecological Model (SEM) as an analytical framework. Methods Our qualitative study was conducted in the three highest endemic regions for malaria in the country. These regions: Adamawa, Centre and North represented different ecological and transmission settings. We collected data through in-depth interviews, key informant interviews and focus group discussions involving caregivers, community members, health workers, community health workers, traditional and religious leaders and malaria programme stakeholders. Interviews were conducted in French, English and Fulfulde using pre-tested interview guides developed according to the SEM framework. Audio-recorded interviews were transcribed verbatim and analysed thematically using NVivo software. Results Our findings revealed that malaria persistence is driven by interconnected factors operating across multiple levels. At the individual level, although respondents generally recognised mosquitoes as the primary vector of malaria, misconceptions linking malaria to witchcraft, fruits, or supernatural causes persisted. Malaria was widely perceived as severe; however, its normalisation as an everyday disease reduced perceived personal vulnerability and weakened adherence to preventive measures. At the interpersonal and community levels, poverty, gendered household decision-making, cultural beliefs, mistrust of health interventions, and environmental conditions such as swampy areas and poor sanitation contributed to delayed treatment-seeking and sustained transmission. Health system barriers included stock-outs of medicines and mosquito nets, poor quality care, corruption, discrimination, and the proliferation of informal street doctors. Policy-level gaps were reflected in the inconsistent implementation of free malaria treatment policies for vulnerable groups. Conclusion The persistence of malaria in Cameroon reflects the interaction of social, cultural, economic, environmental, health system and policy-related factors. Malaria elimination efforts should therefore adopt multi-sectoral, culturally sensitive and community-engaged approaches that strengthen health systems, improve policy implementation, and address structural inequities.