Health Education Research Advance Access originally published online on September 25, 2007
Health Education Research 2008 23(4):612-620; doi:10.1093/her/cym037
Perceived risk factors of cardiovascular diseases and diabetes in Cameroon
1 Health of Populations in Transition Research Group, Diabetes and Endocrine Unit, Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Cameroon
2 Institute of Health and Society, University of Newcastle upon Tyne, UK
3 Institute Nationale de la Santé et de la Recherche Médicale U780-IFR69, 16 avenue Paul Vaillant Couturier, 94087, Villejuif, France
4 The George Institute For International Health, The University of Sydney, Sydney, Australia
5 University of Paris-Sud, Faculty of Medicine, 94276, Kremlin Bicêtre, Cedex, France
* Correspondence to: P. K. Awah. E-mail: awahpaschal{at}yahoo.fr
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Abstract |
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We set out to assess the perceived risk factors of cardiovascular diseases (CVDs) and diabetes mellitus in an urban setting using focus group discussions and in-depth interviews to collect data from different stakeholders constituting the triangle of care. Ethnomethodological analyses were done manually and with Ethnograph® software. The results showed an awareness of emergence of CVD and diabetes in Cameroon and perceived relationships between risk factors and CVD and diabetes. The awareness of behavioural risk factors was higher than the biological ones, though perceptions about them were muddled. The main drawbacks for reducing risk factors were perceived to emerge from the lack of a national policy programme on non-communicable diseases; and the low level of awareness of the need to reduce these risk factors. The assessment illustrates that there is currently a mismatch between the needs and expectations of all the stakeholders regarding health promotion and advice on risk factors reduction and an apparent reluctance by health care providers to fulfil this role. This issue can only be addressed in countries of sub-Sahara through capacity building for control and prevention of CVD risk factors.
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Introduction |
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In addition to the burden of communicable diseases led by malaria and human immunodeficiency virus infection, non-communicable diseases (NCDs) like cardiovascular disease (CVD) are rapidly increasing in Africa. According to the World Health Organization (WHO) [1], CVDs account for 9.2% of total deaths in the African region. Hypertension, stroke, cardiomyopathies and rheumatic heart disease are the primary causes of CVD deaths, and heart failure is becoming more common. WHO estimates that the number of disability-adjusted life years lost due to CVD in sub-Saharan Africa will rise to 8.1 million in men and 7.9 million in women by 2010. Over the years, the fight against infectious diseases has been the main concern of the health authorities of developing countries. Health policies and capacity building have therefore been primarily geared towards reducing infectious diseases associated morbidity and mortality. Cameroon, like most countries in sub-Sahara Africa (SSA), is undergoing an epidemiological transition with the emergence of chronic NCDs like CVD and diabetes [1–7]. Global attention is increasingly focused on the ‘double burden of disease’ (communicable and non-communicable) facing Africa. Poor management of hospital records and the lack of death registration in many African countries limit the accurate ascertainment of the contribution of NCD to diseases and death patterns in SSA. In Cameroon, it has been estimated that deaths due to cardiovascular and metabolic diseases occupied an important place on the mortality list of hospitals; complications of hypertension were ranked the fourth cause of mortality [8]. In all, NCD were responsible for 35% of all deaths among the age group 50 years and above in hospital settings but there are no estimates of quantitative data for other age groups.
In a 1994 survey in Cameroon, obesity (BMI 
30 kg m–2) was found to be more common in urban (16% of men and women) than in rural areas (6% of women and 8% of men). In 1998, another survey revealed that there was also a rural/urban gradient with 16% of women and 5% of men being obese in urban areas as opposed to 3% of women and 1% of men in the rural. In both studies, between 25 and 45% of adults were overweight and obese in urban areas compared with 8–20% in the rural [9]. However, only one qualitative study to explain the knowledge and perception of obesity [10] has been published, leaving us with the task of exploring the wider spectrum of CVD and diabetes risk factors. The lack of both quantitative and qualitative data in Cameroon warrants us to begin with a qualitative study, to provide local concepts that can build up to an evidence-based quantitative one, and eventually set the pace for prevention interventions.
The major problem is whether Cameroonians are aware of the risk factors related to CVD and diabetes. What are the perceptions of people about CVD and diabetes? The focus of this paper is, therefore, to assess the knowledge and perception of different stakeholders on the magnitude and risk factors (biological and behavioural) of CVDs and diabetes, in order to provide baseline qualitative data for the scope and needs for prevention of CVDs. Stakeholders in health services are partners who contribute to the health services research process and outcome: by providing experiential knowledge related to the research outcomes, anticipating and overcoming potential problems with policy implementation, facilitating policy-oriented learning across stakeholder groups, assisting in the transfer of research information to wider stakeholder audiences and promoting acceptance for policy change [11].
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Material and methods |
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Design and setting
The study tools used to collect data were focus group discussions (FGDs) and in-depth interviews (IDIs). This took place from September 2001 to January 2002 at the Biyem-Assi Health District in Yaounde, the capital city of Cameroon. Cameroon is located in West Central Africa. Yaounde has a population of 1.8 million inhabitants. The Biyem-Assi Health District is one of six health districts of Yaounde, with a population of 455,522. There were 25 general practitioners within the health district, 17 specialized medical doctors, 11 pharmacists, 7 hospitals, 13 health centres and 12 pharmacies—both public and private during the study period. The Biyem-Assi Health District has 11 health areas in which 21 health units are unevenly distributed.
The Biyem-Assi Health District has benefited from an intervention on the identification of risk factors of NCDs through anthropomorphological measurements. It currently hosts an intervention project that led to the development of models to improve the quality of care for NCD in general.
The study was exploratory and descriptive. This design is appropriate when the focus of the study is on how and why questions and when the investigator has little control over group interactions. We sought the meanings that these participants attached to the statements related to CVD as had similarly been done by Kleinman [12]. Such a qualitative approach of collecting and managing data is within an interpretative paradigm that deconceptualizes the interpretation and experiences of research participants [13]. Meaning-seeking is the detailed analyses of participant and group behaviour, indicating that illusory correlation can arise from actively seeking intergroup differences and that reinterpretations of behaviour and perceptions are mutually reinforcing. We have conceptualized meaning here as ‘social products’ that are developed through a formative process of interpretation and hold that individuals' definitions of a situation are important guides to their behaviour.
Participants
A total of 82 participants spread out in 12 FGD and 10 IDI made up the total sample. The distribution of categories of participants in the FGD and IDI is presented on Table I.
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The participants were purposively selected. The main characteristic was maximum variation [14]. That is, purposefully picking a wide range of variation on dimensions of interest unique or diverse variations that have emerged in adapting to different conditions with the purpose of identifying important common patterns that cut across variations. It was triangulation in a flexible manner to meet multiple representations. The composition of the groups for FGD was community representatives, health care providers (HCPs)—nurses and physicians, patients, family members caring for patients from within the study community. There were six participants per FGD. The participants for IDIs were policymakers (Senior Government Administrators in the MOH), patients and cardiologists.
Hypertension, diabetes and stroke patients were selected from the clinics where they received care. Patients were excluded from the study if they were newly diagnosed and/or had major disability that hindered them from expressing themselves. Community members were selected from among people living within the Biyem-Assi Health District. HCP were selected from primary, secondary and tertiary health care facilities. Policymakers were directors from the MOH, in charge of designing and executing health policies in Cameroon.
Participants were explained the objective of the study and invited to participate as either participants of FGD or those of IDIs. Assigning participants to the two methods depended on their availability. The individuals for IDI were informed a week before about the objective of the study and appointments taken at their convenience. They were equally reminded about the appointment in the morning of the scheduled date and 2 h before scheduled time. For the FGD, the choice was carefully made so as not to mix people of different backgrounds. Homogeneity was highly respected following professional backgrounds of the HCP and making sure that community members, non-carers of patients, were not mixed with carers of patients and that patients were not mixed with non-patients. Once the participant accepted, contact address was taken and a member of the research team kept in touch until a date of appointment was agreed.
Neutral places were selected for the FGD and for the IDI. This was to avoid frustration or bias responses from the participants, especially if discussions were to be held where the patients received consultations or at the participants' job sites. Public conference rooms were used to conduct FGD for physicians and community members and to enable participants to speak freely. All patients chose to be interviewed in quiet rooms of their homes and policymakers chose to be interviewed in their offices. The Health of Populations in Transition Research Group Cameroon conducted the study, using an adapted core protocol developed by the coordinating center of Global Forum in India. A social scientist trained the team's six researchers on how to use FGD and IDI to collect data for this study. Their skills were tested in a pilot FGD.
Data collection, management and analysis
Data were collected through open-ended questions in the FGD and IDI guides. These were continued until we found that there was redundancy in the subsequent information being collected. Permission was gained to record all the FGD and IDI in audio tapes. The patients were assured that all information would be kept confidential. We explored each participant's experiences and narrative accounts about CVD and diabetes within the overall context. Each IDI or FGD session started with a very broad question permitting us to determine the spontaneity with which CVD and diabetes risk factors were discussed. It also enabled us to elicit participants’ stories in their own words, spontaneous group dynamics and the meaning that they attached to these processes. Since the study was exploratory, we could not follow a particular order of questioning but merely respected the sub-themes set for the study. Probes were used to clarify answers and obtain detailed information on particular topics raised by the informant or by a FGD or to introduce a topic raised by participants in interviews and FGD that were deemed important but not yet raised. Each IDI lasted 30–45 min and each FGD lasted for between 1.5–2 h.
The data management started with debriefing sessions lasting 15 min, always held to review some highlights of the FGD to improve on the quality of subsequent data and set milestones for subsequent work. This facilitated the manual analysis and subsequent writing of summary reports of FGD. All data were transcribed verbatim. The transcripts were typed into a word processing programme to prepare them for analysis. The data were then coded using the Ethnograph software. Some manual analyses were used to check and compare the output of software. The analysis involved the recognition of categories emerging from the data, their patterns, meanings and relationships as had been done by Charmaz [15]. Data segments were also manually reviewed within the context of IDI and FGD in order to develop meaningful codes. Data segments applicable to each code were compared with each other. This was first done with one data set then across other data sets both manually and through Ethnograph. The pseudonyms of participants are used for anonymity. Quotes have been used to amplify and illustrate the perspectives of the informants and participants, relating to the different themes and subgroups identified.
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Results |
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Socio-demographic characteristics
The socio-demographic characteristics of participants in FGD and IDI are presented in Tables II and III. The data are presented as numbers. For age, age groups for FGD and medians have been displayed.
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Magnitude of CVD
The FGD and IDI with HCP indicated a high prevalence of CVDs and diabetes risk factors as illustrated by the quote:
... Diabetes and hypertension are very serious threats to health in Cameroon affecting men and women differently. We have realised that those diseases we used to consider being common with the old have spread young people. They are the second highest causes of mortality. The prevalence rates of both diabetes and hypertension are respectively 2% and 15%. Unfortunately, only 20% of cases are diagnosed. Today many people die suddenly and most are from stroke and heart attack ...In the rest of the FGD and IDI, this opinion was not consistent. Most of the groups said diabetes was frequent in the middle class population and hypertension in the upper and lower classes. When gender-related magnitude was discussed, most participants in the FGD and the IDI explained that hypertension and diabetes were more common in men than women, hence CVDs and diabetes as illustrated by the quote below:
... They affect men than women because men are more stressed in life. When a man is sick in the hospital, he provides money for food in the household and for his hospital bills. But when it is a woman, the man would still provide for her everything for that reason, their blood pressure and blood sugar increases ...
Biological risk factors
Very little was discussed about biological risk factors like dyslipidemia and inflammation markers among members of the community, patients, policymakers and nurses. These risk factors were, however, discussed by physicians. When prompted, most participants accepted that CVDs and diabetes were related. One participant in a FGD with patients declared, "Hypertension and Diabetes are brothers and sisters. They move hand in hand". It was an opinion shared by the rest of the FGD and IDI.
Behavioural risk factors
Diet
All the FGD and IDI established a relationship between diet and CVD, with most groups and participants holding the opinion that nutritional standards are lower now than before. A participant in a FGD with community members declared:
... People now feed poorly because of lack of means. Today a kilo of meat is 2000F [US$4] and a kilo of fish 900F [US$1.8]. The effects here is that most of the food we eat brings about the CVD ...Though fish is cheaper and healthier, people prefer meat as fish is considered as being for the poor and having a poorer nutritional value. The following participant’s declaration by a participant in a group of carers of patients summarizes the different views held by most participants:
... At first we lived healthy on roasted cassavas, cocoyams, and lived well. But now our eating habits have changed. Now we eat ‘mayonnaise’ and also some food crops grown with the help of fertilizers. These in the long run have a negative impact on our health ...Some of the participants in patient groups agreed that they had received advice on feeding but they could not respect because of poverty, as declared by a participant in a FGD with patients:
As concerns my illness, I was asked not to eat groundnuts, palm oil but I cannot respect because I don't have the means.However, all FGD and IDI declared that dietary control contributes towards a healthy living. They affirmed that there has been an evolution in eating habits suggesting that people should change their eating habits by avoiding eating fatty food and eating more vegetables and fruits. Participants also agreed that they have limited access to health care facilities where they could be educated on good eating habits, especially from primary health care units.
Obesity
The FGD and IDI participants decried the rising prevalence of obesity in Cameroon and attributed this to changing lifestyles. They associated this to the increased sedentary lifestyle and to the consumption of fatty and processed foods as illustrated by the following quote:
... When you eat lots of food containing fats and drink much beer it makes you fat. In the past, our grand parents ate little oil and salt but today you fry every food with oil ...The health promotion policy of government was accused for low awareness but no participant expanded on any available risk factors reduction policy. When prompted, participants declared that it could be because CVD were a neglected public health issue. Many participants agreed that obesity could be linked to CVD, diabetes and hypertension emergence. Most of the FGD with patients and carers of patients declared that avoiding overweight is the only lifestyle measure to prevent CVD and diabetes on which they have been provided advice by health care providers.... We thought obesity is an indicator of good living but now obesity involves both rich and poor. We do not more understand the concept. When one is obese, it means there is something wrong .... You will have all diseases related to the heart. But if you are thin or reduce your weight people will think that you have AIDS.
Smoking
All FGD and IDI participants asserted that smoking is more frequent now than before. Most identified smoking as a health hazard declaring that smoking can ‘damage the lungs’ and ‘blacken’ the hands:
More people smoke now out of pride and others with the belief that they will forget problems. Smoking caused hypertension and CVD because your blood and heart is inflamed by hot smoke all the time, but people do not know this.Some participants in FGD or IDI, mainly physicians and policymakers, observed, ‘International conventions recommend smoke-free flights but we doubt if our national flights respect that’.
Alcohol
All participants recognized that alcohol is highly consumed in Cameroon. All of them agreed that people are now more alcohol addicted than ever. One physician in a FGD believed that 
80% of Cameroonians take alcohol and the other participants agreed that alcohol could cause diabetes, hypertension and CVD. A community participant said, ‘alcohol consumption is difficult to stop’ but suggested that the government should sensitize the population on the negative consequences of excessive alcohol consumption.
Most participants explained that older people drink when they want to avoid problems while youths do so for pride as illustrated by the quote of a carer of a patient:
"The youths think it is pride to smoke and drink, but finally they find themselves in these heart diseases and cannot more avoid it."Most of the FGD thought that education is the best means of controlling alcoholism. A nurse, whose opinion spread across other groups, accused the state declaring:
"The state allows the advertisement of cigarettes and beer in the television and through posters all over towns."It was generally discussed that no laws exist in Cameroon to control the production of cigarettes and beer. The application of the law on distribution is weak and hardly respected, especially that relating to the opening hours of pubs and bars. Those to reinforce laws (policemen) were accused of being the first to breach them. This is illustrated by the quote of a policy maker:
"Policemen act as a cover for recalcitrant bar owners because they participate in drinking in bars after closing hours but will not order them to close."
Sedentary lifestyle
All FGD and IDI participants held the view that most people were becoming physically inactive, whereas sports is good for health as illustrated by a participant in a FGD with community members, ... Sports relaxes the body therefore protecting the person from heart diseases ...
Generally, FGD and IDI participants perceived that walking was a good means of exercising but they lacked time to do so. One carer for a patient declared as follows:
... We should not put too much interest to moving only in taxis, but we should also trek. This can prevent diabetes and heart diseases ...
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionFundingConflict of interest statementAcknowledgementsReferences |
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This study used two complementary qualitative data collection tools: IDIs and FGDs. It has provided data on the knowledge and perceptions of various stakeholders on the risk factors of CVD and diabetes. It has also furnished qualitative information on barriers and opportunities for community participation in prevention programmes targeting CVD and diabetes. Most importantly, the study has probed into the main components that build up the triangle of care for NCDs [16], providing some basic evidence that can be used to adapt the integrated chronic care model in low-income countries.
The risk factors of CVDs are well known and documented in both the developed and developing countries. The key modifiable risk factors are smoking, physical inactivity, diet and obesity [17]. Associated and contributory conditions or biomedical abnormalities are diabetes, hypertension and lipid abnormalities (raised cholesterol) which often merely reflect the lifestyle risk factors. The concept of risk factors being at the root of coronary heart disease has been inculcated into physicians for many years with the responsibility for change unconsciously passed to the medical profession. Only recently has there been a realization that biological risk factors are not the only underlying causes. Many risk factors are found within the realm of food, social deprivation, climate change, tobacco, industrialization and urbanization. Socio-economic changes in Africa have transformed people's lifestyles into prosperity thus triggering the emergence of CVDs [17]. However, other groups, especially the poor, are increasingly relying on poor quality low-cost food, following trends set in developed economies.
The main evidence in this paper is that there is a high awareness of the prevalence of CVD and diabetes. People adopt lifestyles, which predispose them to developing these diseases and are not keen about eating healthily, increasing physical activity, losing weight, moderating alcohol and stopping tobacco consumption. Many participants appear to want more lifestyle advice than they currently get. But, this is not always matched by a similar degree of enthusiasm among primary care staff to work with patients on dietary change. This is because the knowledge gap between them, patients and community members may be close. Nutrition-related diseases such as coronary heart disease, stroke, diabetes and obesity increases the burden on health resources in Cameroon and low-income countries with similar backgrounds. Most of these conditions are managed in expensive specialized services, whereas the primary health care providers are well placed to provide a key role in effective prevention.
This study has highlighted the fact that people are aware of the role that stress has on CVD and diabetes, but they think that they cannot do anything about reducing it. This may explain why people acknowledge that they have not changed their lifestyles. Changes to the intake of fat, salt and fibre as well as fruit and vegetable and fish consumption have produced beneficial effects and improved the management of hypertension, dyslipidaemia and diabetes [16]. But such evidence is not yet available in low-income countries because of the perceived benefits accrued from them. Studies conducted by Meisler and St Jeor [18] on overweight illustrated that relatively small amounts of weight loss may lead to meaningful improvements in blood pressure, blood lipids, glucose control and insulin levels. But these are issues that are still pending to be addressed in Cameroon and many low-income countries because they are usually not within the scope of health priorities. Efforts at addressing these issues are mainly made by individual researchers rather than governments because the double burden of disease prevalence diverts the scarce resources to the heavily financed infectious diseases rather than the unprioritized CVD and diabetes [7].
The globality of CVDs warrants a global and integrated approach to prevention. This explains our rationale of exploring different stakeholders in the triangle of health care, a way of stitching their different views together and suggesting a model for tackling the emergence of CVD and diabetes. Very few studies have qualitatively explored the perceived risk factors of CVD and diabetes. The most recent has been that of Kiawi et al. [10] using IDI and only focusing on obesity as a risk factor of diabetes from the patient perspective. We have therefore highlighted different opinions in qualitative terms, defining the voices of the people that are involved in daily health care for CVD and diabetes. The significance of this is to lay a framework for the quantification of these findings and the development of acceptable health promotion interventions for the prevention and care of CVD and diabetes. For now, the only available health promotion activity in Cameroon related to reducing CVD risk factors is that of maternal and child care, designed to care for pregnant women and infants.
From this study, it is clear that people and governments scorn smoking and are able to relate it to the current emergence of CVD and diabetes. This ties with the findings of Poole-Wilson [17]. But government action is slower and far less targeted because of conflict of interest which overwrite general statements of well-being. Furthermore, the implementation of the WHO Global Strategy on Diet, Physical Activity and Health has not yet got a place in countries' health. Reports from organizations have largely ignored the problem of CVD until 2005 when an overview of the problem was highlighted by WHO, considering it as a major problem. This study has confirmed the common perception that CVD and diabetes are diseases of the elderly and affluence [17]. These perceptions indicate the incorrect ways people think about CVD coupled with the fact that governments do not necessarily consider these diseases as very important to invest in, on grounds that the young people are unaffected. We further highlight avenues of collaboration between lay people, public health officials, the public and HCP, as an essential component of collaboration to build into a health promotion package. Since physicians are those who mainly know the biological and behavioural risk factors, obviously because they are knowledgeable and manage patients living with them, it is therefore time to act by setting up interventions that target all stakeholders. This effort can be successful if a strong international effort is set up to encourage country-led preventive initiatives. However, the most important forces of change have to be responding to the request of the grassroots and then building the capacity of HCP and reinforcing government state apparatus. If emphases are laid on risk factor reduction, health education on CVD and diabetes for primary health care teams could promote a model of dietary, alcohol, smoking, obesity and physical activity interventions that is applicable within the current organization of primary care within Cameroon and SSA.
Some limitations have to be accounted for when interpreting the findings from this study. The first limitation has to do with the unavailability of data on traditional healers, who may be vital partners for some health promotion activities. This paper is also limited by the paucity of quantitative data on the burden of CVD risk factors in Cameroon. Therefore, a quantitative survey is required to complement these results. The Cameroon Burden of Diabetes Baseline Survey, as logical consequence of this study, would fulfil this requirement.
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Funding |
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Global Forum for Health under the Initiative for Cardiovascular Health.
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Conflict of interest statement |
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TopAbstractIntroductionMaterial and methodsResultsDiscussionFundingConflict of interest statementAcknowledgementsReferences |
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None declared.
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Acknowledgements |
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The administrative, local and health authorities in the Biyem-Assi Health District are also acknowledged for their cordial relationship with us during the fieldwork. We thank Dr Graham Garnham and Mrs Ann Garnham for proof reading this manuscript.
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References |
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Received on April 12, 2006; accepted on June 20, 2007
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