Intervention
The lesson of Monsieur Nouma: Effects of a culturally sensitive communication tool to improve health-seeking behavior in rural Cameroon

https://doi.org/10.1016/j.pec.2011.11.007Get rights and content

Abstract

Objective

To test the effect of patient counseling using educational tools, on rates of return for follow-up in newly diagnosed hypertensive and/or diabetic patients in a rural African context.

Methods

Free screening for hypertension and elevated blood glucose was offered in primary health care centers in central Cameroon during 9 campaigns of 3 days each. Individuals with untreated hypertension and/or diabetes were divided into 2 groups: a control group receiving counseling according to routine procedures, and an intervention group receiving counseling with different educational tools to explain the diagnosis and its implications to the patient.

Results

Prevalence of hypertension and/or diabetes in the screened population was 41%. At 3 months from screening, rates of return visits were higher in the intervention group than in the control group: 55/169 (32%) vs. 15/92 (16%), OR 2.4; 95%CI 1.3–4.7; p < 0.001.

Conclusion

Screening may identify untreated individuals efficiently. Rates of return visits after screening, although low in both groups, could be doubled by a short communication intervention.

Practice implications

This study suggests that modest communication interventions, e.g., the application of educational tools, may bring important benefits and increase the effectiveness of public health measures to combat chronic diseases in settings of limited resources.

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)

  • W.K. Bosu

    Epidemic of hypertension in Ghana: a systematic review

    BMC Public Health

    (2010)
  • O.O. Oladapo et al.

    A prevalence of cardiometabolic risk factors among a rural Yoruba south-western Nigerian population: a population-based survey

    Cardiovasc J Afr

    (2010)
  • Cited by (10)

    • Diabetes in sub-Saharan Africa: from clinical care to health policy

      2017, The Lancet Diabetes and Endocrinology
      Citation Excerpt :

      Patient education has also been used in several settings to improve services across the care continuum and to decentralise care away from hospitals to the patient level. For example, in Cameroon, motivational counselling and education were integrated into a screening programme to improve rates of follow-up for patients newly diagnosed with diabetes.253 In South Africa, group education was used at community health centres to improve patients' knowledge and management of diabetes, although no improvements were seen in diabetes self-care activities, weight loss, HbA1c concentrations, quality of life, self-efficacy, locus of control, blood pressure, waist circumference, or total cholesterol levels.144

    View all citing articles on Scopus
    View full text