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

Abstract

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.

Figures

Figure 1

One-year retention of diabetic and hypertensive patients. Attrition among the 349 patients who were recruited at least 15 months before the assessment. Lost to follow-up was defined as no recorded consultation for ≥ 3 months.

Figure 2

Change of blood pressure among hypertensive patients. Changes in systolic and diastolic blood pressure between the visit where treatment was started (usually the second visit) and the last follow-up visit. Dots are displaying mean values, bars the 95% confidence interval. Groups are according to the WHO grade of hypertension at initiation of therapy. Grade 1 n = 82; grade 2 n = 160; grade 3 n = 196). All changes are significant (p < 0.001).

Figure 3

Change of fasting plasma glucose among diabetic patients. Change in fasting plasma glucose levels between the visit where treatment was started (usually the second visit) and the last follow-up visit among diabetic patients. Dots are displaying mean-values, with brackets indicating the 95% confidence interval. The changes in both groups are significant (sample with 7-10.9 mmol/l at the start of the treatment (n = 35), p-value = 0.0151; sample with≥ 11 mmol/l at the start of the treatment (n = 44), p < 0.001).