Precarious hope and reframing risk behavior from the ground up: insight from ethnographic research with Rwandan urban refugees in Yaoundé, Cameroon.

BACKGROUND: Theoretical and methodological research on risk-taking practices often frames risk as an individual choice. While risk does occur at individual level, it is determined by aspirations which are connected to others and society. For many displaced women globally, these aspirations are often linked to the well-being of their children and other household members. This article explores the links between aspirations for the future, gendered household dynamics, and health risk-taking behavior among the Rwandan urban refugee community. METHODS: This analysis drew from participant observation, focus group discussions, and in-depth interviews with 49 male and 42 female household members from 36 Rwandan refugee households in Yaoundé, Cameroon. The fieldwork was conducted over 12 months between May-August 2016, May-August 2017, and February-August 2018. RESULTS: We observed that while there was considerable convergence among household members in aspirations, there was considerable difference in risk-taking practices engaged to achieve them with women often assuming the greatest risks. These gendered realities of risk were not only related to structural concerns including access to different forms of capital, but also to socio-cultural gendered expectations of women, how risks were defined and justified, and household dynamics that drove the gendered reality of observed risk-behavior. CONCLUSIONS: Humanitarian programs and policies are distinctly finite in nature; focused on the short-term needs of persons affected by conflict. However, many humanitarian situations in the world are protracted. In the midst of these challenges, themes of future-orientation, possibilities, and shared aspirations for a better future emerge. These aspirations and the practices, including risk-taking practices that stem from them are central to understand if we are to ensure a just peace and stability in displaced communities throughout the developing world. Our analysis highlights the need to examine sociocultural dimensions related to hopes for the future, gender, and household dynamics as a way to understand risk behavior. We propose this can be done through a framework of precarious hope which we put forward in this paper, in which hope, agency, sociocultural and political economic contexts situate risk as a gendered practice of hope amidst constraint.

Developing a Buruli ulcer community of practice in Bankim, Cameroon: A model for Buruli ulcer outreach in Africa.

BACKGROUND: In the Cameroon, previous efforts to identify Buruli ulcer (BU) through the mobilization of community health workers (CHWs) yielded poor results. In this paper, we describe the successful creation of a BU community of practice (BUCOP) in Bankim, Cameroon composed of hospital staff, former patients, CHWs, and traditional healers. METHODS AND PRINCIPLE FINDINGS: All seven stages of a well-defined formative research process were conducted during three phases of research carried out by a team of social scientists working closely with Bankim hospital staff. Phase one ethnographic research generated interventions tested in a phase two proof of concept study followed by a three- year pilot project. In phase three the pilot project was evaluated. An outcome evaluation documented a significant rise in BU detection, especially category I cases, and a shift in case referral. Trained CHW and traditional healers initially referred most suspected cases of BU to Bankim hospital. Over time, household members exposed to an innovative and culturally sensitive outreach education program referred the greatest number of suspected cases. Laboratory confirmation of suspected BU cases referred by community stakeholders was above 30%. An impact and process evaluation found that sustained collaboration between health staff, CHWs, and traditional healers had been achieved. CHWs came to play a more active role in organizing BU outreach activities, which increased their social status. Traditional healers found they gained more from collaboration than they lost from referral. CONCLUSION/ SIGNIFICANCE: Setting up lines of communication, and promoting collaboration and trust between community stakeholders and health staff is essential to the control of neglected tropical diseases. It is also essential to health system strengthening and emerging disease preparedness. The BUCOP model described in this paper holds great promise for bringing communities together to solve pressing health problems in a culturally sensitive manner.

Research Ethics Committees (RECs) and epidemic response in low and middle income countries.

The recent Ebola and Zika virus epidemics in some parts of Africa and Asia have showcased the porosity in disaster preparedness and response, not only in the affected countries, but on a global scale. For the Ebola epidemic, scientifically robust research was started late during the course of the epidemic, with waste of resources and lost research opportunities. Research Ethics Committees have a significant role to play with regards to epidemic response for the future. This paper presents key challenges and opportunities for ethics review during emergencies, specifically for low and middle income countries. There is no better moment to test the efficacy and safety of drugs or vaccines for infected, or at risk populations than during the disaster itself. The main mantras that form the back bone of research ethics review (Helsinki Declaration, the CIOMS International Ethical Guidelines for Biomedical Research Involving Human Subjects, WHO and the ICH guidelines for Good Clinical Practice) are increasingly showing their limitations. Most protocols are generally from developed countries where the funding originates. Not only is the direct transposition to Low and Middle Income Country (LMIC) settings inappropriate on its own, also, using such guidelines in times of public health disasters might be time consuming, and might also lead to wastage of research opportunities, especially when sociocultural peculiarities, and anthropological research arms are completely excluded or avoided within the care and research packages. Governments should include RECs as key members during the elaboration, and daily functioning of their national public emergency response packages. Developing simple research ethics review guidelines, involvement of health care staff in ethics training, community mobilization, and incorporation of anthropological research during the medical response, research and communication phases, are imperatives in epidemic response.

Yaws resurgence in Bankim, Cameroon: The relative effectiveness of different means of detection in rural communities.

BACKGROUND: Yaws is an infectious, debilitating and disfiguring disease of poverty that mainly affects children in rural communities in tropical areas. In Cameroon, mass-treatment campaigns carried out in the 1950s reduced yaws to such low levels that it was presumed the disease was eradicated. In 2010, an epidemiological study in Bankim Health District detected 29 cases of yaws. Five different means of detecting yaws in clinical and community settings were initiated in Bankim over the following five years. METHODOLOGY: This observational study reviews data on the number of cases of yaws identified by each of the five yaws detection approaches: 1) passive yaws detection at local clinics after staff attended Neglected Tropical Disease awareness workshops, 2) community-based case detection carried out in remote communities by hospital staff who relied on community health workers to identify cases, 3) yaws screening following mass Buruli Ulcer outreach programs being piloted in the district, 4) school-based screening programs conducted as stand-alone and follow-up activities to mass outreach events, and 5) house to house active surveillance activities conducted in thirty-eight communities. Implementation of each of the four community-based approaches was observed by a team of health social scientists tasked with assessing the strengths and limitations of each detection method. FINDINGS: Eight hundred and fifteen cases of yaws were detected between 2012 and 2015. Only 7% were detected at local clinics. Small outreach programs and household surveys detected yaws in a broad spectrum of communities. The most successful means of yaws detection, accounting for over 70% of cases identified, were mass outreach programs and school based screenings in communities where yaws was detected. CONCLUSION: The five interventions for detecting yaws had a synergistic effect and proved to be valuable components of a yaws eradication program. Well planned, culturally sensitive mass outreach educational programs accompanied by school-based programs proved to be particularly effective in Bankim. Including yaws detection in a Buruli Ulcer outreach program constituted a win-win situation, as the demonstration effect of yaws treatment (rapid cure) increased confidence in early Buruli ulcer treatment. Mass outreach programs functioned as magnets for both diseases as well as other kinds of chronic wounds that future outreach programs need to address.

Ethical implications of HIV self-testing: the game is far from being over.

The use of combined Anti-Retroviral Therapy (cART) has been revolutionary in the history of the fight against HIV-AIDS, with remarkable reductions in HIV associated morbidity and mortality. Knowing one's HIV status early, not only increases chances of early initiation of effective, affordable and available treatment, but has lately been associated with an important potential to reduce disease transmission. A public health priority lately has been to lay emphasis on early and wide spread HIV screening. With many countries having already in the market over the counter self-testing kits, the ethical question whether self-testing in HIV with such kits is acceptable remains unanswered. Many Western authors have been firm on the fact that this approach enhances patient autonomy and is ethically grounded. We argue that the notion of patient autonomy as proposed by most ethicists assumes perfect understanding of information around HIV, neglects HIV associated stigma as well as proper identification of risky situations that warrant an HIV test. Putting traditional clinic based HIV screening practice into the shadows might be too early, especially for developing countries and potentially very dangerous. Encouraging self-testing as a measure to accompany clinic based testing in our opinion stands as main precondition for public health to invest in HIV self-testing. We agree with most authors that hard to reach risky groups like men and Men Who Have Sex with Men (MSM) are easily reached with the self-testing approach. However, linking self-testers to the medical services they need remains a key challenge, and an understudied indispensable obstacle in making this approach to obtain its desired goals.

Ebola Virus Diseases in Africa: a commentary on its history, local and global context.

Ebola Virus Disease (EVD) started as a minor infection in Uganda in 1974 and has been frequent in Central Africa Region for the past 40 years. For over 40 years, Ebola was treated as an African disease, called a fever and known by other names where occurrences have been frequent. EVD has become a global public health threat following the most recent outbreak in West Africa. By December 31, 2014, Ebola has infected more than 23,500 people in West Africa and killed over 9,500, nearly all in the three worst-affected countries of Guinea, Liberia and Sierra Leone. It is transmitted through blood, vomit, diarrhea and other bodily fluids but cultural attributes associate its etiology to man-made and supernatural causes, hence stemming public health approaches to contain EVD difficult. Distrust and conflict between two healing systems are rife necessitating an African Model of EVD care and prevention. The African model remains indispensable to understand EVD and developing appropriate EVD containing approaches.

Malnutrition in Sub-Saharan Africa: burden, causes and prospects.

Malnutrition is estimated to contribute to more than one third of all child deaths, although it is rarely listed as the direct cause. Contributing to more than half of deaths in children worldwide; child malnutrition was associated with 54% of deaths in children in developing countries in 2001. Poverty remains the major contributor to this ill. The vicious cycle of poverty, disease and illness aggravates this situation. Grooming undernourished children causes children to start life at mentally sub optimal levels. This becomes a serious developmental threat. Lack of education especially amongst women disadvantages children, especially as far as healthy practices like breastfeeding and child healthy foods are concerned. Adverse climatic conditions have also played significant roles like droughts, poor soils and deforestation. Sociocultural barriers are major hindrances in some communities, with female children usually being the most affected. Corruption and lack of government interest and investment are key players that must be addressed to solve this problem. A multisectorial approach is vital in tackling this problem. Improvement in government policy, fight against corruption, adopting a horizontal approach in implementing programmes at community level must be recognized. Genetically modified foods to increase food production and to survive adverse climatic conditions could be gateways in solving these problems. Socio cultural peculiarities of each community are an essential base line consideration for the implementation of any nutrition health promotion programs.

Public awareness, knowledge and practice relating to epilepsy amongst adult residents in rural Cameroon--case study of the Fundong health district.

INTRODUCTION: Epilepsy associated stigma remains a main hindrance to epilepsy care, especially in developing countries. In Africa, anti-epileptic drugs are available, affordable and effective. As of now, no community survey on epilepsy awareness and attitudes has been reported from this area Cameroon with a reported high prevalence of epilepsy. METHODS: To contribute data to the elaboration of the National Epilepsy Control Programme, we carried out a cross-sectional descriptive community survey of 520 households. We had as main objective to obtain baseline data on the knowledge, attitudes and practice of adults towards epilepsy in rural Cameroon, and compare with existing data. RESULTS: Most respondents had heard or read about epilepsy, knew someone who had epilepsy and had seen someone having a seizure. The most frequently cited cause of epilepsy was witchcraft. Most subjects believed epilepsy is contagious. Epilepsy was a form of madness or insanity to 33.5% of them. Only 54.9% of respondents would meet a medical doctor for the treatment. Most respondents would not permit equal employment opportunities, association and child's marriage to someone with epilepsy. Age, female sex and level of education were associated to negative attitudes (p<0.001). CONCLUSION: Adults in Fundong are very acquainted with epilepsy but have many erroneous beliefs about the condition. Their attitudes are generally negative. The National Epilepsy Programme must insist on modes of transmission, treatment options and first aid measures during epileptic seizures. The elderly (>50 years) and those without any formal education should be the main targets during health information, education and communication programmes.

Type 2 diabetes management in nurse-led primary healthcare settings in urban and rural Cameroon.

AIMS: To implement a protocol-driven primary nurse-led care for type 2 diabetes in rural and urban Cameroon. METHODS: We set-up three primary healthcare clinics in Yaounde (Capital city) and two in the Bafut rural health district. Participants were 225 (17% rural) patients with known or newly diagnosed type 2 diabetes, not requiring insulin, referred either from a baseline survey (38 patients, 17%), or secondarily attracted to the clinics. Protocol-driven glucose and blood pressure control were delivered by trained nurses. The main outcomes were trajectories of fasting capillary glucose and blood pressure indices, and differences in the mean levels between baseline and final visits. RESULTS: The total duration of follow-up was 1110 patient-months. During follow-up, there was a significant downward trend in fasting capillary glucose overall (p<0.001) and in most subgroups of participants. Between baseline and final visits, mean fasting capillary glucose dropped by 1.6 mmol/L (95% CI: 0.8-2.3; p< or =0.001). Among those with hypertension, blood pressure also decreased significantly for systolic and marginally for diastolic blood pressure. No major significant change was noticed for body weight. CONCLUSIONS: Nurses may be potential alternatives to improve access to diabetes care in settings where physicians are not available.

Setting-up nurse-led pilot clinics for the management of non-communicable diseases at primary health care level in resource-limited settings of Africa.

BACKGROUND: This article describes the setting-up process for nurse-led pilot clinics for the management of four chronic diseases: asthma, type 2 diabetes mellitus, epilepsy and hypertension at the primary health care level in urban and rural Cameroon. METHODS: The Biyem-Assi urban and the Bafut rural health districts in Cameroon served as settings for this study. International and local guidelines were identified and adapted to the country's circumstances. Training and follow-up tools were developed and nurses trained by experienced physicians in the management of the four conditions. Basic diagnostic and follow-up materials were provided and relevant essential drugs made available. RESULTS: Forty six nurses attended six training courses. By the second year of activity, three and four clinics were operational in the urban and the rural areas respectively. By then, 925 patients had been registered in the clinics. This represented a 68.5% increase from the first year. While the rural clinics relied mainly on essential drugs for their prescriptions, a prescription pattern combining generic and proprietary drugs was observed in the urban clinics. CONCLUSION: In the quest for cost-effective health care for NCD in sub-Saharan Africa, rethinking health workforce and service delivery has relevance. Nurse-led clinics, algorithm driven service delivery stands as alternatives to overcome the shortage of trained physicians and other issues relating to access to care.

Nurse-led care for asthma at primary level in rural sub-Saharan Africa: the experience of Bafut in Cameroon.

BACKGROUND AND PURPOSE: Asthma is an important health condition in sub-Saharan Africa, with major gaps in clinical care. The aim of this project was to implement nurse-led care for asthma in rural Cameroon. METHODS: We set-up a nurse-led structured management program for asthma in Bafut rural health district in Cameroon from 1998 to 2000. After an initial phase of intensive medical supervision, nurses were offered to run the clinics independently. Patients were monitored for all-cause mortality, hospitalizations, and control of asthma attacks. RESULTS: At the final evaluation, 87 (73.4% women) were registered in the two pilot clinics. They were 4 to 92 years of age (median 51) and had been diagnosed with asthma for 0 to 40 years. The median duration of follow-up was 5 months (range 1-20) and patients attended on average 3 visits (range 1 to 14). During follow-up, a 66-year-old participant died and 170 emergency hospital admissions/consultations were recorded in 34 participants, 82.3% of them being women. Overall there was a significant downward trend in the number of days/month with attacks with the duration of follow-up, and at the last visit most patients had improved compared with the initial visit. This trend was apparent in most subgroups of participants. Hospital admission before baseline visit was a predictor of hospital admission during follow-up, hazard ratio (95% confidence interval) 3.20 (1.30-7.91), p = 0.012. CONCLUSIONS: The program was well received by the community at large. A marked improvement was observed for most patients as substantiated by the reduction in the number of asthma attacks. Trained nurses are a good alternative for the management of asthma in a resource-limited context.

Cure or control: complying with biomedical regime of diabetes in Cameroon.

BACKGROUND: The objective of the study was to explore the cultural aspect of compliance, its underlying principles and how these cultural aspects can be used to improve patient centred care for diabetes in Cameroon. METHODS: We used participant observation to collect data from a rural and an urban health district of Cameroon from June 2001 to June 2003. Patients were studied in their natural settings through daily interactions with them. The analysis was inductive and a continuous process from the early stages of fieldwork. RESULTS: The ethnography revealed a lack of basic knowledge about diabetes and diabetes risk factors amongst people with diabetes. The issue of compliance was identified as one of the main themes in the process of treating diabetes. Compliance emerged as part of the discourse of healthcare providers in clinics and filtered into the daily discourses of people with diabetes. The clinical encounters offered treatment packages that were socially inappropriate therefore rejected or modified for most of the time by people with diabetes. Compliance to biomedical therapy suffered a setback for four main reasons: dealing with competing regimes of treatment; coming to terms with biomedical treatment of diabetes; the cost of biomedical therapy; and the impact of AIDS on accepting weight loss as a lifestyle measure in prescription packages. People with diabetes had fears about and negative opinions of accepting certain prescriptions that they thought could interfere with their accustomed social image especially that which had to do with bridging their relationship with ancestors and losing weight in the era of HIV/AIDS. CONCLUSION: The cultural pressures on patients are responsible for patients' partial acceptance of and adherence to prescriptions. Understanding the self-image of patients and their background cultures are vital ingredients to improve diabetes care in low-income countries of Sub-Sahara Africa like Cameroon.

The burden of high blood pressure and related risk factors in urban sub-Saharan Africa: evidences from Douala in Cameroon.

OBJECTIVE: To provide the current burden of high blood pressure and related risk factors in urban setting in Cameroon. METHODS: We used the WHO STEPS approach for Surveillance of non-communicable diseases and their risk factors to collect data from 2,559 adults aged 15-99 years, residing at Cite des Palmiers in Douala, Cameroon. RESULTS: The level of education was low with up to 60% of participants totalizing less than primary school. Smoking habits were 6 times more frequent in men (p<0.001) and 85% of participants reported alcohol consumption. Sedentary lifestyles at work and at leisure time were prevalent. Women displayed high prevalence of obesity in general. The mean blood pressure and the prevalence of hypertension increased with age in men and women. The prevalence of hypertension was 20.8%, and the risk of hypertension significantly increased with clustering of risk factors in the general population (p=0.001) and in men (p=0.008). CONCLUSIONS: This study provides additional evidence on the growing problem of hypertension and related risk factors in urban Cameroon; and confirms the feasibility of using the WHO STEPS approach for the surveillance of NCDs in Africa. There is a need for rapid implementation of preventive strategies in the country.

HIV/AIDS occurrence in the main university teaching hospital in Cameroon: audit of the 2001 activities of the service of internal medicine.

AIM: This study describes the impact of HIV/AIDS on the inpatient service of the main teaching hospital in Cameroon in 2001. METHODS: The authors analyzed routinely collected hospital data and data validated by survey of clinical notes. RESULTS: Admission and bed utilization rates for HIV/AIDS over the period accounted for 20.1% and 17%, respectively, primarily due to the management of opportunistic infections in young people (mean age, 39.9 years). Housewives (21.9%) and students (10.3%) were the most identified groups. Tuberculosis (23.3%), the most frequent infection, was associated with a good prognosis. Hospital stay ranged from 1 to 99 days. HIV/AIDS accounted for 49.3% of deaths registered. CONCLUSION: HIV/AIDS is the major cause of hospital admissions and death in this service. This situation is likely to remain constant for some time given the national prevalence of HIV. Consideration needs to be given to the options for prevention and provision of care.