Therapeutic Routes of a Group of Heart Failure Patients Followed in a Cameroonian Urban Setting ()
1. Introduction
Heart failure (HF) is a large group of cardiovascular diseases, the leading cause of death worldwide [1] . It is distinguished by its frequency, mortality and poor prognosis [2] . It is a common disease that affects 1% to 2% of the adult population in developed countries [3] . This prevalence is steadily increasing with the ageing of the general population ages. It is worth mentioning that the diseases that lead to HF are often associated with ischemic heart disease and hypertension, which may cause HF [4] .
In Africa, HF is the most common cause of hospitalisation in people suspected of cardiovascular disease [5] . In Cameroon, HF is a threaded public health issue due to its high prevalence rates, as evidenced by the in-hospital prevalence rates of acute HF found at 30% and 33.3%, respectively, in 2014 and 2015 Cardiology Department of Yaoundé Central Hospital [6] . Patients with HF tend to use several therapies to relieve their symptoms. Nowadays, their health-seeking behaviours, which include different therapeutic modalities, different places of care, and treatment care routes (hospitals and sites of complementary and alternative medicine), are multiple and give the patient a wide range of treatment options that are often harmful, not conventional. These different treatment care routes can be defined as the succession of care recourse from the beginning to the end of the disease. It comprises all the patient and his family’s paths searching for health [7] .
The factors that come into play in the choice of treatment are numerous. These include economic constraints, cultural beliefs, disease, and the health system’s organisation and functioning [8] . According to the World Health Organization, a health system is a set of organisations, institutions, resources, and people whose main objective is improving health [9] . In Cameroon, it is organised around a pyramidal structure at three levels: the main level (decision-making), the intermediate level (regional), and the peripheral level (operational), each of which has administrative structures, health facilities and dialogue structures [10] . Public health facilities are classified into six categories, from general hospitals to integrated health centres. This system has certain limitations. In fact, in the organisation of African health services like those of Cameroon, the recovery of health costs is mainly provided by households [11] . In other words, the population (the patient and his family relatives) bears all health costs [11] . Also, some authors report unequal access to population care in health infrastructures. This inequality is due to insufficient first-referral health facilities and insufficient collaboration between first-category hospitals and lower-referral facilities [12] . Without, however, guaranteeing the quality of the services offered, accessibility to these healthcare infrastructures is sometimes synonymous with long waits, ineffective treatments and lack of medications [7] . Faced with these difficulties, patients’ needs that cannot be met in certain hospitals are rising. We can observe a diversification of treatment courses that are sometimes very dangerous for patients’ health [13] . Indeed, the treatment care routes do not always coincide with those predetermined by the health services. It is one of the significant determinants of the delay in access to specialize care due to the lengthening of treatment care routes. This delay is not without consequences on the evolution of a patient’s state of health. It is responsible in some cases for diagnostic and therapeutic delays of pathologies, especially those of chronic evolution such as HF. Hence, the importance of knowing the therapeutic routes of patients. This study’s main objective is to describe the therapeutic route of heart failure patients consulting in two central-level hospitals in Yaoundé, Cameroon.
2. Material and Methods
2.1. Study Design, Settings, and Participants
We conducted a prospective cross-sectional study between December 2018 and July 2019 (6 months) at two major cardiology and internal medicine departments of Yaoundé, Cameroon’s political capital. These were the cardiology department of Yaoundé Central Hospital (YCH). The YCH, located in the district of Yaoundé 2, is a central-level hospital equipped with several units, including one of medicine and Specialties and an imaging department or additional examinations such as electrocardiography (ECG) echocardiography can be performed with a capacity of 650 beds in the hole hospital and 32 beds in the cardiology department. Using consecutive convenient sampling, we recruited all consenting patients aged ≥ 18 with HF confirmed based on Framingham criteria during the study period [14] .
2.2. Data Collection Procedure and Studied Variables
After obtaining ethical clearance from the Institutional Review Board of the “Université des Montagnes” and research authorisation from the different the two hospitals included in the study: 1) we identified during outpatient consultations the patients meeting the various eligibility criteria; 2) then, we explained to the patients the purpose, importance and modalities of the conduct of the study and obtain their informed consent; 3) the participants were subjected to a questionnaire pretested and prevalidated, with the help of a language translator allowing information to be collected on socio-demographic data (age, sex, profession, level of education, ethnicity, religion, marital status), personal history (the circumstances of discovery of HF, initial symptoms such as dyspnoea, weight gain, oedema of the lower limbs, fatigue), consultation characteristics (the time elapsed between the onset of symptoms and the first medical consultation), the different types of care structure (district hospitals, regional hospitals, central hospitals and general hospitals), types of treatment (complementary and alternative medicine, auto-medication, religious, abstention from treatment), the patient’s motivations for going to a facility, the interventions in each resort, the duration of treatment at each treatment station (the time spent in each treatment station from consultation to discharge), the time between each recourse, the clinical evolution (accentuation of clinical symptoms present at the start or reduction of clinical symptoms present at the beginning), diagnostic time (the time elapsed between the first medical consultation and the time when the diagnosis was made), total number of treatment options; 4) analysis of the data collected; 5) the interpretation of the results obtained.
2.3. Definitions of Operational Terms
The therapeutic route also called the treatment care route, is the path patients and their families take to search for health. The ideal route is a progressive referral approach between primary health care centres, usually run by state registered nurses and general practitioners, followed by secondary care hospitals like district hospitals and regional hospitals run by general practitioners and medical specialists and finally, tertiary care hospitals such as Central hospital or General Hospital. The pseudo-ideal route is one leap at most in the different stages of the health pyramid. The Erratic Route does not follow the various steps of the health pyramid. Recourse to care is a request for care addressed to people or institutions that do not always define themselves as caregivers. The consultation time is the halfway point between the onset of the initial symptoms and the first consultation in a care structure. The diagnostic delay is the time between the beginning of the initial signs and the HF diagnosis. Auto-medication is the use of drugs taken on the patient’s initiative. The natural practice is an action that we carry in a banal way, either because we are used to it or because it takes away from us (our daily life or culture). The traditional healer or therapist is an individual who exercises an unconventional medical practice based on approaches presented as standard in some African communities. Non-specific treatment is patient management that has nothing to do with heart failure.
2.4. Statistical Analysis
Data entry and data analysis were done using EPI-INFO version 7.2 software. The results were expressed in terms of the mean ± standard deviation for the quantitative variables and frequency and percentage for qualitative variables. The Student’s t-test was used for normally distributed continuous variables. Nonparametric tests in case of constant variables not following a normal distribution law. P-values less than 5% were considered statistically significant.
2.5. Ethical Considerations
Ethics clearance was obtained from the Institutional Ethics Committee of the Université des Montagnes (Authorization No. 2019/153/UdM /PR /CIE), followed by securing research authorisations from the head management of each study hospital. The study was carried out following the fundamental principles of medical research of the Declaration of Helsinki [4] and Good clinical practice principles.
3. Results
3.1. General Characteristics of Participants
Our population comprised 132 HF patients: 83 women (62.88%) and 49 men (37.12%). The average age of our patients was 62.90 years, with extremes ranging from 21 to 96 years. The most represented age group was 50 to 70 years old in 50.76% of cases. The majority level of education was primary (35.61%). Less than half (31.82%) had a fixed monthly income. Their average monthly income was 148,880 FCFA, equivalent to 270 US dollars, with a minimum of 30,000 FCFA, equivalent to 54 US dollars and a maximum of 450,000 FCFA, equal to 816 US dollars. The most common causes of HF were hypertension with 50%, dilated cardiomyopathy (15.15%), and valvular heart disease (12.12%). The most common comorbidity was chronic kidney disease (6.06%). The most common cardiovascular risk factors were high blood pressure 68.94%, obesity (18.94%), and diabetes (15.15%). NYHA Stage II (43.94%) and III dyspnea were the most represented (49.34%). See Table 1.
3.2. Therapy for Heart Failure
The most prescribed drug classes were diuretics (92.42%) and Angiotensin-con- verting enzyme inhibitors (ACEI)/Angiotensinogen II receptor antagonists (ARB II) (81.82%). The most prescribed molecules are respectively furosemide (93.44%) for the class of diuretics, nebivolol (52.54%) for the type of beta-blockers, perindopril (38.89%) for the class of ACEI/ARB II, digoxin (13.85%) for the digitalis class and spironolactone (14.06%) for the antialdosterone class. See Table 2.
3.3. The Different Stages of the Therapeutic Route and the Effects of Interventions Carried out on Patients
To describe HF patients’ various steps in their different therapeutic routes, we excluded patients already followed for another cardiovascular pathology other than HF at YCH, i.e. 17 patients. The patients needed one (6.25%), two (62.25%), three (25.89%), and four resorted therapeutic routes (25.89%). Most of our patients (73.68%) resided in Yaoundé, and 70 (62.25%) resorted to two therapeutic routes. Regarding auto-medication, 48 patients (36.36%) resort to it. Modern self-medication (buying drugs from a pharmacy without a prescription by a treating staff) and complementary and alternative medication were found in 26 patients (57.78%) and 32 patients (72.73%), respectively. A statistically significant difference between the time elapsed between the first symptoms and the consultation of the first referral in patients residing in Yaoundé and those living far from Yaoundé with a p-value of 0.0033 (Table 3). Likewise, a statistically significant difference between the time elapsed between the first symptoms and the HF diagnosis in patients residing in Yaoundé and those living far from Yaoundé with a p-value of 0.003 (Table 3).
![]()
Table 1. General characteristics of the study population.
1 US dollar = 553.89 at the time of this study.
![]()
Table 2. Treatment of heart failure.
ACEI: Angiotensin-converting enzyme inhibitors, ARB II: Angiotensin II receptor blockers.
![]()
Table 3. Comparative table of the time elapsed between the first symptoms and the consultation in the first resort and the time elapsed between the first symptoms and the diagnosis in patients from Yaoundé and those living far from Yaoundé.
3.4. Therapeutic Routes of Patients with Heart Failure Followed in Yaoundé
Patients residing in Yaoundé resorted to more than ten therapeutic routes (see Figure 1). Patients spend an average of 30.18 days at home before seeking treatment. The first most frequented care structures are the integrated health centre (IHC) 35.71%, 15.47% in district hospitals (DH), and 15.47% at Jamot Hospital (JH). After spending approximately 18.63 days on average in the first structure, some decided to resort to a second structure for better care, which was a specialised structure, YCH (72.72%) or JH (7.80%). See Figure 1. Half of our patients had a pseudo-ideal route, with one jump at most in the health pyramid’s different stages.
A single patient had an ideal therapeutic route therapeutic routes following all the stages of the health pyramid in our health system, i.e. home → IHC (nurse) → primary care hospital/District Hospital → CMA / DH (general practitioner) → regional hospital or HR (general practitioner, specialist) → YCH (specialist). See Table 4.
![]()
Table 4. Summary of the itineraries of resident patients in Yaoundé.
![]()
Figure 1. Summary of the therapeutic routes taken by patients residing in Yaoundé. Key: District Hospitals (DH), Jamot Hospital (JH), Yaounde Central Hospital (YCH), Integrated Health Centre (IHC).
The patients residing near Yaoundé (not longer than 30 km from their homes to a place of care) mainly had five therapeutic routes (Figure 2).
Patients spend an average of 9.21 days at home before seeking treatment. The first most frequented care structures are the IHC (69.23%), the DH (23.07%), and the traditional practitioner (23.07%). After having done about 41.30 days on average in the first structure, some decided to have recourse to a second structure to have better care, which, for the most part, was a specialised structure for YCH (81.81%) or JH (18.18%). Of the 13 patients living near Yaoundé, 11 patients (84.61%) had a pseudo-ideal itinerary. See Table 5.
Patients living far away from Yaoundé (longer than 30 km from their homes to a place of care) had different routes from patients residing in Yaoundé and near Yaoundé. We have listed more than ten routes (Figure 3).
Patients spend an average of 48.66 days at home before seeking treatment. The first most frequented care structures are the IHC (42.10%), the DH (22.23%), the Regional Hospital (RH) (11.12%) and the JH (11.12%). After having done about 89.11 days on average in the first structure, some decided to have recourse to a second structure to have better care which, for the most part, was a specialised structure for YCH (61.12%) or the JH (16.67%). Of the 18 patients living far from Yaoundé, 15 patients had a pseudo-ideal itinerary (see Table 6).
![]()
Table 5. Summary of the itineraries of patients residing near Yaoundé.
![]()
Figure 2. Summary of the therapeutic routes taken by patients residing close to Yaoundé. Key: District Hospitals (DH), Jamot Hospital (JH), Yaounde Central Hospital Hospital (YCH), Integrated Health Center (IHC).
![]()
Figure 3. Summary of the therapeutic routes taken by patients residing far away from Yaoundé. Key: District Hospitals (DH), Jamot Hospital (JH), Yaounde Central Hospital Hospital (YCH), Integrated Health Centre (IHC).
![]()
Table 6. Summary of the routes of patients residing far from Yaoundé.
3.5. Reason for Adopting a Remedy
Patients’ primary motivations for going to the first therapeutic resort were geographic proximity (52.57%) and advice from someone (31.82%). On the other hand, patients went to the second resort either because the symptoms persisted (44.76%) or because they had been referred by a health professional (14.28%) or because they considered that the disease was severe and therefore decided to go to a structure superior to the previous one for better management (see Table 7).
3.6. Determine the Effect of Therapeutic Routes on the Condition of Patients upon Their Arrival in a Cardiology Department
The time between the first symptoms and the first resort’s consultation was longer in the group living far from Yaoundé than in Yaoundé, with a significant difference. Likewise, we note that the time elapsed between the first symptoms and the diagnosis of HF is higher in patients with NYHA stage III-IV HF at the time of diagnosis with a statistically significant p-value of 0.0019 (see Table 8).
4. Discussion
This prospective cross-sectional study’s objective was to describe the therapeutic routes of patients with heart failure from the onset of the first symptoms until the moment of treatment in a specialised cardiology unit to determine this impact on the patient’s condition at the time of diagnosis. Our findings were that very few patients (0.90%) followed an ideal route, 60.71% of subjects had a pseudo ideal route, 19.64% went directly to a specialised structure, and 21.42% used an erratic route. On arrival in a cardiology setting, 49.24% and 35.61% of our patients were in severe stage III and IV IC according to the NYHA classification, compared to 15.15% for stage II. None were in stage I.
We observed that most (63.64%) opted to abstain from therapy before being consulted regarding patients’ therapeutic routes. Therefore, auto-medication does not occupy a prominent place in the treatment of HF in the current study. Indeed, very few subjects (36.36%) resorted to auto-medication; in its investigation of the therapeutic route of HF patients in Cameroon, Nkoma et al. in 2015
![]()
Table 7. Difference from the motivative of patients to visit the different healthcare structures.
![]()
Table 8. Comparative table of the time elapsed between the first symptoms and the consultation in the 1st resort and the time elapsed between the first symptoms and the diagnosis in patients with stage I-II and stage III-IV HF on arrival.
IQI: interquartile interval.
established that auto-medication represented 51.9% of intentions to use and that only 3.4% of patients opted for abstention from treatment [7] . The study participants chose to abstain from therapy because of the progressive onset of HF’s clinical picture; symptoms are very mild initially and will gradually worsen. Patients do not even recognise the signs of the disease. Therefore, taking any medication is seen as an additional risk of the condition worsening.
At the first therapeutic resort, most patients went to modern health structures (80.63%); only 4.46% resorted to complementary and alternative medicine (CAM), and 16.96% went to other remedies (pharmacies and private hospitals or clinics). These results show a high frequency of modern consultations. It can be explained by the geographical proximity between the patient’s residence and the health facilities attended. In his study of the therapeutic route of epilepsy patients in Yaoundé, Mbonda et al. 2008 also demonstrated that at the first therapeutic resort, 72.5% of patients were consulted in modern health facilities [15] . On the other hand, in the same study, he observed that 25.5% of patients had recourse to CAM [15] . CAM is more frequent in epileptic patients because epilepsy is perceived as a pathology with supernatural origins. The many beliefs surrounding this condition make this remedy a persistent remedy by those patients [15] . The most frequented modern health structures are the CSI, the HD, and the JH (a second category hospital specialising in pulmonology), respectively 41.96%, 17.85%, and 13.40% resorts. The main reasons are geographical proximity in 52.57% or someone’s advice in 37.50%.
The most consulted health structure was the JH (19.04%) at the second and third therapeutic options. The main reasons mentioned, among others, are the persistence of symptoms such as dyspnea (44.76%), referral by a health professional (19.64%) or fear of the severity of the disease (14.28%). At least one of these reasons persuaded them to go to a higher structure than the previous one for better care. The clinical presentation of HF mimics a respiratory problem that leads patients to believe that they have a lung problem and seek a pulmonologist. At the fourth resort, patients choose between the YCH because of the availability of quality infrastructure and specialised doctors; the one hand, as a last therapeutic resort referred by the health structures.
Upon arrival in a cardiology unit, more than half of the HF patients (84.85%) were at a late stage (49.24%) for NYHA stage III and 35.61% for NYHA stage IV against 15.15% for NYHA stage II. Kingue and al. in 2005 obtained only 53% of patients with NYHA stage III and IV of [16] . Heart failure is a condition still unknown to the population nowadays, and most of the time, they access specialised care late. The factors associated with the delay in diagnosis were an elevated time between the first symptoms and the consultation of the first referral high (p statistically significant at 0.0546). A time elapsed between the first symptoms and high HF diagnosis (statistically significant p to 0.0019). In other words, the longer the patient takes to see an appropriate health facility, the more likely he is to be late when the disease is diagnosed.
Our study’s limitations are its small sample size (n = 132), making our results generalised with caution to all HF patients in Cameroon. However, this study is one of the first to concisely describe the different therapeutic routes taken by HF patients from symptom onset to specialised cardiology treatment. Hence, it identifies poor health-seeking behaviours that should draw HF patients’ attention to the necessity of timely hospital presentation for early treatment and management. These are two significant determinants of HF patients’ good prognosis.
5. Limitations
Our study has some limitations, notably the sample size, which remains modest, as well as its implementation in intrahospital and urban settings.
6. Conclusion
The current study findings suggest that few HF patients follow an ideal course; most have had a pseudo-ideal or erratic route. It results in a diagnosis of severe HF on arrival in a specialised health centre for more than half of the patients. This delay in therapy was associated with a long time between the first symptoms and the consultation of the high first resort on the one hand, and a long time between the first symptoms and the diagnosis of HF on the other hand, as well as a total number of appeals greater than one. Based on these results, we should intensify therapeutic education on HF patients and promote postgraduate formation on HF for healthcare providers.
Declaration
Authors Contribution
Conception and design: CNNG, SK;
Data collection: CNNG, MDD, BH;
Data analysis and interpretation: MDD, JNT;
Manuscript drafting: CNNG, JNT;
Manuscript revision: CNNG, JNT;
Approval of the final manuscript: All the authors.
Availability of Data and Materials
The datasets used for this study are available from the corresponding author upon request.
Ethical Approval and Consent to Participate
The Institutional Ethical Review Board of the Université des Montagnes (Cameroon) approved the study. All the participants read and signed informed consent before their inclusion in the study.
Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.
Nganou-Gnindjio, C.N., Hamadou, B., Djampouop, M.D., Gwet, M.N., Kamdem, F., Mintom, P., Ndobo, J.V., Djibrilla, S., Manon, G.E., Tochie, J.N. and Kingue, S. (2023) Therapeutic Routes of a Group of Heart Failure Patients Followed in a Cameroonian Urban Setting. World Journal of Cardiovascular Diseases, 13, 686-700. https://doi.org/10.4236/wjcd.2023.1310061
References
- 1. OMS (2023) à propos des maladies cardiovasculaires. WHO. https://www.who.int/cardiovascular_diseases/about_cvd/fr/
- 2. Pio, M., Afassinou, Y., Pessinaba, S., Baragou, S., N’djao, J., Atta, B., Ehlan, E., Damorou, F. and Goeh-Akué, E. (2014) Epidémiologie et étiologies des insuffisances cardiaques à Lomé [Epidemiology and Etiology of Heart Failure in Lome]. The Pan African Medical Journal, 18, 183.
- 3. Gabet, A., Lamarche-Vadel, A., Chin, F., Juillière, Y., De Peretti, C. and Olié, V. (2014) Mortalité due à l’insuffisance cardiaque en France, évolutions 2000-2010. Bull Epidémiol Hebd, 21-22.
- 4. Mbewu, A. and Mbanya, J.-C. (2006) Cardiovascular Disease. In: Dean, T.J., Richard, G.F., Malegapune, W.M., Eduard, R.B., Florence, K.B., Karen, J.H. and Khama, O.R., Eds., Disease and Mortality in Sub-Saharan Africa. World Bank, Washington.
- 5. Bloomfield, G.S., Barasa, F.A., Doll, J.A. and Velazquez, E.J. (2013) Heart Failure in Sub-Saharan Africa. Current Cardiology Reviews, 9, 157-173. https://doi.org/10.2174/1573403X11309020008
- 6. Boombhi, J., Moampea, M., Kuate, L.M., Menanga, A.P., Hamadou, B. and Kingue, S. (2017) Clinical Pattern and Outcome of Acute Heart Failure at the Yaounde Central Hospital. Open Access Library Journal, 4, e3478. https://doi.org/10.4236/oalib.1103478
- 7. Nkoma, P.P. (2015) Itinéraires thérapeutiques des malades au Cameroun: Les déterminants du recours à l’automédication. 7ème Conférence sur la Population Africaine: “Dividende Démographique en Afrique: Perspectives, Opportunités et Défis”, le Gouvernement de l’Afrique du Sud et l’Union pour l’Etude de la Population Africaine (UEPA), Johannesburg, Afrique du Sud.
- 8. Moha, M. (2012) Les itinéraires thérapeutiques Université Gaston Berger-Saint Louis Sénégal Janvier. https://www.google.cm/Pluralismemédicaldéfinition
- 9. OMS (2018) à propos des systèmes de santé. WHO. https://www.who.int/healthsystems/about/fr/
- 10. OMS (2018) Cartographie et évaluation approfondie des systèmes d’approvisionne- ment et de distribution des médicaments et autres produits de santé au Cameroun. WHO. https://www.who.int/healthsystems/about/fr/
- 11. Mondiale bank.org. Cameroun (2013) Un meilleur accès à la santé pour tous les Camerounais. http://www.banquemondiale.org/fr/country/cameroon/publication/better-healthcare-access-for-all-cameroonians
- 12. Charlotte, M.N. (2011) Contribution du controle de gestion à la performance des hopitaux publics au Cameroun, Mémoire, Université Catholique d’Afrique Centrale. https://www.memoireonline.com/
- 13. Yves-Merlin, M.K. (2002) Pluralisme thérapeutique et stratégies de santé au Cameroun. Octobre, 42.
- 14. McKee, P.A., Castelli, W.P., McNamara, P.M. and Kannel, W.B. (1971) The Natural History of Congestive Heart Failure: The Framingham Study. The New England Journal of Medicine, 285, 1441-1446. https://doi.org/10.1056/NEJM197112232852601
- 15. Mbonda, N.M., Kuate, C., Nguefack, S., Chiabi, A., Mbonda, P.C., Njamnshi, A.K., et al. (2008) Itinéraire Thérapeutique Des Patients Epileptiques à Yaoundé: A propos de 149 observations. Clinics in Mother and Child Health, 5, 893-898.
- 16. Kingue, S., Dzudie, A., Menanga, A., Akono, M., Ouankou, M. and Muna, W. (2005) Nouveau regard sur l’insuffisance cardiaque chronique de l’adulte en Afrique à l’ère de l’échocardiographie Doppler: Expérience du service de médecine de l’Hopital Général de Yaoundé. Annales de Cardiologie et d’Angéiologie, 54, 276-283. https://doi.org/10.1016/j.ancard.2005.04.014