Recruitment strategies to promote uptake of cervical cancer screening in the West Region of Cameroon.

OBJECTIVES: The World Health Organization's (WHO) global strategy for cervical cancer elimination has set the target of 70% of women screened in all countries by 2030. Community sensitization through media is often used, but community health workers' (CHW) involvement may contribute to improving screening coverage. We aimed to assess effectiveness and costs of two cervical cancer screening recruitment strategies conducted in a low-resource setting. METHODS: The study was conducted in the West Region of Cameroon, in the Health District of Dschang, a community of 300,000 inhabitants. From September 2018 to February 2020, we recruited and screened women for cervical cancer in a single-visit prevention campaign at Dschang District Hospital. During the first 9 months, recruitment was only based on Community Information Channels (CIC) (e.g.. street banners). From the tenth month, participation of CHW was added in the community after training for cervical cancer prevention counselling. Population recruitment was compared between the two strategies by assessing the number of recruited women and direct costs (CHW costs included recruitment, teaching, certification, identification badge, flyers, transport, and incentives). The intervention's cost-effectiveness was expressed using an incremental cost-effectiveness ratio (ICER). RESULTS AND DISCUSSION: During the period under study, 1940 women were recruited, HPV positive rate was 18.6% (n = 361) and 39 cases of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) were diagnosed. Among included participants, 69.9% (n = 1356) of women were recruited through CIC as compared to 30.1% (n = 584) by CHW. The cost per screened woman and CIN2+ diagnosed was higher in the CHW group. The ICER was 6.45 USD or 16.612021Int'l$ per screened woman recruited by CHW. Recruitment in rural areas increased from 12.1 to 61.4% of all women included between CIC-led and CHW-led interventions. These outcomes highlight the importance of training, preparing, and deploying CHW to screen hard-to-reach women, considering that up to 45% of Cameroon's population lives in rural areas. CONCLUSION: CHW offer an important complement to CIC for expanding coverage in a sub-Saharan African region such as the West Region of Cameroon. CHW play a central role in building awareness and motivation for cervical cancer screening in rural settings.

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

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.

Improved retention rates with low-cost interventions in hypertension and diabetes management in a rural African environment of nurse-led care: a cluster-randomised trial.

OBJECTIVE: To compare the effects of low-level facility-based interventions on patient retention rates for cardiovascular (CV) disease in an environment of task shifting and nurse-led care in rural health districts in Central Cameroon. METHODS: This study is an open-label, three-arm, cluster-randomised trial in nurse-led facilities. All three groups implemented a treatment contract. The control group (group 1) had no additional intervention, group 2 received the incentive of 1 month of free treatment every forth month of regularly respected visits, and group 3 received reminder letters in case of a missed follow-up visit. 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. Patients' monthly spending for drugs and transport was calculated retrospectively. RESULTS: A total of 33 centres and 221 patients were included. After 1 year, 109 patients (49.3%) remained in the programme. Retention rates in groups 2 and 3 were 60% and 65%, respectively, against 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 antihypertensive 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 patients with diabetes. 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 CV disease management in rural Africa. The combination of a treatment contract and reminder letters in case of missed appointments was an effective measure to retain patients in care.

Task shifting to non-physician clinicians for integrated management of hypertension and diabetes in rural Cameroon: a programme assessment at two years.

BACKGROUND: The burden of non-communicable chronic diseases, such as hypertension and diabetes, increases in sub-Saharan Africa. However, the majority of the rural population does still not have access to adequate care. The objective of this study is to examine the effectiveness of integrating care for hypertension and type 2 diabetes by task shifting to non-physician clinician (NPC) facilities in eight rural health districts in Cameroon. METHODS: Of the 75 NPC facilities in the area, 69 (87%) received basic equipment and training in hypertension and diabetes care. Effectiveness was assessed after two years on status of equipment, knowledge among trained NPCs, number of newly detected patients, retention of patients under care, treatment cost to patients and changes in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients. RESULTS: Two years into the programme, of 54 facilities (78%) available for re-assessment, all possessed a functional sphygmomanometer and stethoscope (65% at baseline); 96% stocked antihypertensive drugs (27% at baseline); 70% possessed a functional glucose meter and 72% stocked oral anti-diabetics (15% and 12% at baseline). NPCs' performance on multiple-choice questions of the knowledge-test was significantly improved. During a period of two years, trained NPCs initiated treatment for 796 patients with hypertension and/or diabetes. The retention of treated patients at one year was 18.1%. Hypertensive and diabetic patients paid a median monthly amount of 1.4 and 0.7 Euro respectively for their medication. Among hypertensive patients with ≥ 2 documented visits (n = 493), systolic BP decreased by 22.8 mmHg (95% CI: -20.6 to -24.9; p < 0.0001) and diastolic BP by 12.4 mmHg (-10.9 to -13.9; p < 0.0001). Among diabetic patients (n = 79) FPG decreased by 3.4 mmol/l (-2.3 to -4.5; p < 0.001). CONCLUSIONS: The integration of hypertension and diabetes into primary health care of NPC facilities in rural Cameroon was feasible in terms of equipment and training, accessible in terms of treatment cost and showed promising BP- and FPG-trends. However, low case-detection rates per NPC and a very high attrition among patients enrolled into care, limited the effectiveness of the programme.

Bridging the gap: how traditional healers interact with their patients. A comparative study in Cameroon.

OBJECTIVE: To compare traditional healers (TH) and Cameroonian representatives of Western medicine (Western providers (WP)) in terms of patient characteristics and communication patterns during the consultation in rural Cameroon. METHODS: A facility-based comparative study was conducted. Seven TH were compared to eight WP in the same district. Patients (five per provider) provided detailed socio-demographic data. Recorded consultations were analysed with the Roter Interaction Analysis System (RIAS). RESULTS: Patients were similar in socio-demographic characteristics except for age, where TH patients were on average 9 years younger (P < 0.05). Patients of TH travelled 2.5 times as far to their provider as did patients in the WP group (79 vs. 31 km; P < 0.05) and paid 12 times more for their treatment (123 vs. 10 Euros; P < 0.05). Consultations of TH were shorter (5.6 vs. 10.3 min, P < 0.01), had fewer utterances (100 vs. 166, P < 0.05) and the patient's share in the communication was smaller (P < 0.01). TH had a higher percentage of lifestyle and psychosocial information at the expense of medical information (P < 0.05) and communicated more emotionally (P < 0.001). They asked more frequently for their patients' opinion (P < 0.01) and explicitly discussed their patients' concept of illness (P < 0.001). Patients of TH responded with a higher percentage of active communication (P < 0.05) i.e. question asking (P < 0.01). CONCLUSIONS: Our data contradict the idea that the lack of money or geographical access to Western health care in rural Africa is the main reason for people to consult traditional healers. Compared to WP, TH interacted very differently with their clients, using a more patient-centred communication style, to seek common ground with patients. This different type of interaction could be a relevant factor contributing to the popularity of traditional healers in Cameroon.

Early assessment of the implementation of a national programme for the prevention of mother-to-child transmission of HIV in Cameroon and the effects of staff training: a survey in 70 rural health care facilities.

OBJECTIVES: To assess the availability of equipment and the staff's knowledge to prevent Mother-To-Child Transmission (PMTCT) in rural healthcare facilities recently covered by the national PMTCT programme in Cameroon. METHODS: In eight districts inventories of antiviral drugs and HIV test kits were made on site, using a standardised check-list. Knowledge of HIV and PMTCT was evaluated with a multiple-choice (MC) questionnaire based on typical clinical PMTCT cases. Staff participated subsequently in a 2-day training on HIV/AIDS and the Cameroon PMTCT guidelines. Immediately after training and after 7 months, retention of knowledge was tested with the same questions but in different order and layout. RESULTS: Sixty two peripheral nurse-led clinics and the eight district hospitals were assessed. Whereas all district hospitals presented complete equipment, only six of the peripheral clinics (10%) were equipped with both complete testing materials and a full set of drugs to provide PMTCT. Thirty six peripheral facilities (58%) possessed full equipment for HIV-testing and 8 (13%) stocked all PMTCT drugs. Of 137 nurses, 102 (74%) agreed to the two knowledge tests. Fewer than 66% knew that HIV-diagnosis requires positive results in two different types of rapid tests and only 19% chose the right recommendation on infant-feeding for HIV-positive mothers. Correct answers on drug regimens in different PMTCT settings varied from 25% to 56%. All percentages of correct answers improved greatly with training (P < 0.001) and retention remained high 7 months after training (P < 0.001). CONCLUSIONS: Prevent Mother-To-Child Transmission programmes in settings such as rural Cameroon need to be adapted to the special needs of peripheral nurse-led clinics. Appropriate short training may considerably improve nurses' competence in PMTCT. Other important components are regular supervision and measures to guarantee supply of equipment in rural areas.

Provider-patient interaction in rural Cameroon--how it relates to the patient's understanding of diagnosis and prescribed drugs, the patient's concept of illness, and access to therapy.

OBJECTIVE: This cross-sectional survey examines the relation between provider-patient interaction and several patient-outcomes in a rural health district in Cameroon. METHODS: We used structured patient interviews and the Roter Interaction Analysis System (RIAS) for analysis of audio-recorded consultations. RESULTS: Data from 130 primary care consultations with 13 health-care providers were analysed. 51% of patients correctly named their diagnoses after the consultation; in 47% of prescribed drugs patients explained correctly the purpose. Patients' ability to recall diagnoses was related to the extent of clarity a provider used in mentioning it during consultation (recall rates: 87.5% if mentioned explicitly, 56.7% if mentioned indirectly and 19.2% if not mentioned at all; p<0.001). Two thirds of patients were able to describe their concept of illness before the consultation, but only 47% of them mentioned it during consultations. On average patients who mentioned their disease concept were faced with more remarks of disapproval from providers (1.73 vs 0.63 per consultation; p<0.01). Although 41% of patients admitted problems with financial resources to buy prescribed drugs, discussion about financial issues was very rare during consultations. Providers issued financial questions in 32%, patients in 21% of consultations. CONCLUSION: This study shows that provider-patient interaction in primary health care in a rural Cameroon district deserves more attention. It might improve the patients' knowledge about their health condition and support them in beneficial health behaviour. PRACTICE IMPLICATIONS: Our findings should encourage providers to give more medical explanation, to discuss patients' health beliefs in a non-judgmental manner, and to consider financial issues more carefully.