InterventionThe lesson of Monsieur Nouma: Effects of a culturally sensitive communication tool to improve health-seeking behavior in rural Cameroon
Introduction
Chronic non communicable diseases, in particular cardiovascular diseases (CVD) pose an enormous challenge to health systems, especially in low and middle income countries. Already struggling with acute infectious diseases and HIV, health-care systems are unprepared to tackle exploding rates of illnesses such as hypertension, diabetes and overweight. This is a serious shortcoming, as in these countries CVD is the leading cause of morbidity and death in people aged over 35 years [1], [2], [3].
CVD prevention is most efficiently achieved by controlling risk factors, e.g., hypertension, over a long period of time. This requires several conditions to be fulfilled in sequence: (1) individuals at risk must be identified (2) individuals’ awareness of illness must translate into care-seeking behavior, (3) lifestyle-measures and long-term treatment must be adhered to, and (4) treatment response needs to be adequate.
In high income countries, where over 75% of cases are detected [4] and the frequency of routine consultations is high, conditions 3 and 4 are most in need to be tackled [5]. In developing countries, however, the major challenges are underdetection (less than 30% identified) [6] and high drop-out rates [7]. The latter tend to be highest at the beginning of therapy: drop-out rates of around 30–50% within the first 3 months and 80% within the first year have been reported from hypertension programs in Cameroon [8], [9], Tanzania [10] as well as the Seychelles [11]. The reason seems partly to be patients’ high out-of pocket expenditure on treatments and transport [12], [13]. In addition, observational studies from different African countries have identified lack of awareness about the nature and the possible consequences of hypertension and diabetes as a major barrier to retention and treatment adherence [14], [15]. In Tanzania, more than half of hypertensive patients could not list a single complication of hypertension when asked [10].
Faced with these facts, measures to identify, educate and motivate untreated individuals to return for follow-up are urgently needed. However, such initiatives will need to take into account the limited financial resources available in low-income settings.
Individuals diagnosed with an illness typically go through a process of change before actively seeking help and treatments. This starts with acknowledging the problem and reaching the conclusion that the problem is worth tackling. This mentally prepares the individual to take action and seek care [16]. This process of change can be influenced and encouraged by patient-centered counseling techniques such as motivational interviewing [17].
In low- and middle-income countries, communication training for healthcare staff in other disease areas has been shown significantly to increase individuals’ awareness, satisfaction, as well as rates of return for follow up visits [18]. Furthermore, the use of visual communication aids, e.g., illustrated patient information leaflets (PILs), has been shown to be very effective to communicate health messages. Such tools improve the emotional impact, recall of information, and adherence to treatment in different contexts, including in African patients [reviewed in Ref. [19]]. The impact seems greatest in low-literacy populations, as demonstrated for correct drug administration and compliance in non-literate women in Cameroon [20].
In the present study we hypothesized that in order to address the first two conditions (to identify individuals at risk and to promote care-seeking behavior), two interlinked interventions would be needed. We thus conducted screening campaigns to detect individuals at risk, and combined the campaigns with motivational counseling at the time of screening to increase the rate of participants who returned for follow up and treatment.
The main objective of the study was to test the impact of counseling with an educational tool on rates of return for follow up in newly diagnosed Individuals with hypertension and/or diabetes, compared with routine procedures. The effect of communication aids like PILs on participants’ motivation to return for follow-up, has to our knowledge not been tested before in the context of cardiovascular conditions, certainly not in Sub Saharan Africa.
A secondary objective was to investigate the usefulness of screening campaigns measured on detection rates of individuals at risk and on return rates for follow-up.
Section snippets
Study setting
The study was conducted in the health districts of Mfou, Mbankomo, Soa and Obala, which are all situated in the central province of Cameroon. All districts are included in a chronic disease program (Programme de lutte contre les maladies chroniques [PLMC]) run by the Cooperation Cameroon Jura Suisse. This primary health care project covers an estimated 400,000 habitants in eight rural or semi-urban districts. The program has implemented hypertension and diabetes type 2 care in all primary
Participant flow
Participants’ flow through the study is shown in Fig. 1. A total of 837 individuals participated in the screening and data on 825 participants were analyzed (12 individuals were excluded because of incomplete data). 339 individuals (41%) screened positively for hypertension and/or diabetes. Among those, 70 (21%) were currently under treatment and were excluded from the study. The remaining 269 (79%) were considered as treatment-naive with 83 (31%) aware of their condition but untreated and 186
Discussion
Identifying individuals at risk and translating disease awareness into care-seeking behavior are two corner stones in CV risk prevention. The results of the present small-scale study shows that screening campaigns are a highly efficient way to identify individuals at risk, but modifying behavior remains a major challenge. However, we found that rates of return visits (≥1) within three months after screening positively for hypertension and/or diabetes could be tripled in newly diagnosed
References (25)
- et al.
A review of non-communicable disease in low- and middle-income countries
Intern Health
(2009) The double burden of communicable and non-communicable diseases in developing countries
Trans R Soc Trop Med Hyg
(2006)- et al.
The effect of an educational intervention on patients’ knowledge about hypertension, beliefs about medicines, and adherence
Res Social Adm Pharm
(2009) - et al.
The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence
Patient Educ Couns
(2006) - et al.
Design, development, and evaluation of visual aids for communicating prescription drug instructions to nonliterate patients in rural Cameroon
Patient Educ Couns
(1997) - et al.
Blood-pressure-related disease is a global health priority
Lancet
(2008) The World health report 2008 – primary health care (now more than ever)
(2009)Preventing chronic diseases: a vital investment: WHO global report 2005
(2006)- et al.
Prevalence, awareness, treatment, and control of hypertension among United States adults 1999–2004
Hypertension
(2007) - et al.
Achieving blood pressure goals globally: five core actions for health-care professionals. A worldwide call to action
J Hum Hypertens
(2008)
Epidemic of hypertension in Ghana: a systematic review
BMC Public Health
A prevalence of cardiometabolic risk factors among a rural Yoruba south-western Nigerian population: a population-based survey
Cardiovasc J Afr
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