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Task Shifting for Integrated Management of Hypertension and Diabetes in Rural Cameroon: An Observational Cohort Assessment at Two Years

Author(s): N. D. Labhardt*1, J. Balo2, M. Ndam3, E. Manga3
Affiliation(s): 1Swiss Tropical Institute, University of Basel, Basel, Switzerland, 2District Hospital Mbankomo, 3District Hospital Mfou, Ministry of Public Health of Cameroon, Mfou, Cameroon
Keywords: Non-communicable chronic diseases, Task shifting, Integrated care, Non-physician clinicians, Diabetes, Hypertension
Background:

Sub Saharan Africa (SSA) faces a looming epidemic of arterial hypertension and diabetes for which most countries are not prepared. We tested in eight rural Cameroonian districts a model of integrated care by task shifting of the management of hypertension and diabetes from hospitals to facilities led by non-physician clinicians (NPCs).

Methods:

After a preliminary survey in 75 peripheral health centres, 69 were subsequently trained and equipped for prevention, diagnosis and treatment of hypertension and type 2 diabetes. Two years later the effectiveness of the programme was assessed by the status of equipment and drugs in formerly equipped facilities (1), knowledge among trained NPCs, assessed by a multiple-choice questionnaire (2), number of newly detected and followed patients (3) and trend in blood pressure (BP) and fasting plasma glucose (FPG) among treated patients (4).

Results/Conclusions:

(1): At baseline only 49 (65%) of the 75 health centres were equipped to measure BP and 11 (15%) to measure FPG. Twenty (27%) disposed of an anti-hypertensive and nine (12%) of an anti-diabetic drug. Two years after training and equipment of NPCs, all had still a functional sphygmomanometer and stethoscope, 96% an antihypertensive drug on stock, 70% had a functional glucose meter and 72% an oral anti-diabetic drug on stock. (2): Knowledge about hypertension among nurses was poor before training (on average 41% of correct answers per question), improved dramatically after the course and remained high at two-years (on average 80% of correct answers) (p<0.001). (3): Of the 796 newly detected patients, 2579 visits of 222 patient-years were recorded. Of all patients 562 (70.6%) were lost to follow-up at the time data were collected. Of these, most (75%) were lost during the first three months. (4): Among hypertensive patients with ≥ 2 visits (n=438), systolic BP decreased by 23.5mmHg (CI95%: 20.5-26.6; p<0.0001) and diastolic BP by 12.5mmHg (10.6-14.5; p<0.0001). Among diabetic patients with ≥2 visits (n=79) FPG decreased by 3.4mmol/l (1.8-5.1; p<0.001).
In conclusion, integrated management of hypertension and diabetes by nurses in general NPC facilities in rural settings with limited resources is feasible on a district scale. NPCs were successfully trained and equipped and their patients showed a good treatment response. However, a relatively low case-detection rate per NPC and a very low retention rate in the program at two years severely limit the effectiveness.

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