Improved care for cardiovascular disease and diabetes management in a rural African environment of nurse-led care – an experience in Cameroon

Context:
In Cameroon, high blood pressure (HBP) and diabetes are a more and more frequent condition of chronic disease. WHO estimates 28% of men and 18% of women aged between 35 and 54 affected by HBP. In the same groupe, 4.2% of men and 2.8% of women are suffering from diabetes. The primary care structures should be enabled to manage those diseases – by training of the staff, appropriate drug supply and strategies to better retain the patients in the follow-up.

Objective:

• To compare the effects of low-level facility-based interventions on patient retention rates for cardiovascular disease in an environment of task shifting and nurse-led care in rural health districts in Central Cameroon.
• To share the results of the study with health professionals of the region and based on their experience, to build up treatment recommendations for cardiovascular diseases.

Methods:

• Open label, three-arm, cluster-randomised trial in nurse-led facilities. All three groups implemented a treatment contract. Two interventions were tested: a financial incentive of 1 month of free treatment for patients who regularly attended follow-up visits (Group 2 ) and reminder letters in case of a missed follow-up visit (Group 3). The primary outcome was patient retention at 1 year. Secondary outcomes were adherence to follow-up visit schemes and changes in blood-pressure (BP) and blood-glucose levels.
• A local symposium to bring together primary health care staff, experts and health authorities to brief on the result of this study and to share further experiences of the different participants.

Results:

• 33 centres and 221 patients were included. At 1 year, 109 patients (49.3%) remained in the programme. Retention rates in Groups 2 and 3 were 60% and 65% respectively, compared with 29% in the control group. The differences between the intervention groups and the control group were significant (p<0.001), but differences between the two intervention groups were not (p=0.719). There were no significant differences in BP or fasting plasma glucose trends between retained patients in the study groups. Average monthly cost to patients for anti-hypertensive medication was € 1.1 ± 0.9 and for diabetics €1.2 ±1.1. Transport costs to the centres were on average €1.1 ±1.0 for hypertensive patients and  €1.1 ±1.6 for diabetics.
• The symposium put 60 health staff from all 28 districts (8 were involved in the study), experts from the University Hospital and representatives of the health ministry of the central region in Cameroon together for a two day workshop. They adopted a treatment guide used in the study area, discussed issues in relation to the continuing medical education and the management of other chronic diseases.

Conclusions:

• Low-cost interventions suited to an environment of task shifting and nurse-led care and needing minimal additional resources can significantly improve retention rates in cardiovascular disease management in rural Africa. Reducing transport expenditures for patients by decentralising the management of hypertensive and diabetic patients to peripheral NPC-clinics might improve access without increased strain on healthcare budgets.
• To share study results in a form of a symposium permitted to motivate the team for further rigorous care, to share different experiences in the field of chronic disease management, to benefit to train health staff of an entire region and to adopt new and feasible strategies to control cardiovascular disease and diabetes. 

Contacts:

Dr Beat Stoll, MPH
Institute of Social and Preventive Medicine,
University of Geneva,
1211 Geneva 4, Switzerland
beat.stoll@unige.ch

Dr Engelbert Manga, MPH
Health district officer
Mfou / Cameroun
e.manga@gmx.net