Two decades of tobacco use prevention and control policies in Cameroon: results from the analysis of non-communicable disease prevention policies in Africa.

BACKGROUND: Tobacco use is the leading cause of preventable death in the world today. In 2010, the World Health Organization (WHO) proposed efficient and inexpensive "best buy" interventions for prevention of tobacco use including: tax increases, smoke-free indoor workplaces and public places, bans on tobacco advertising, promotion and sponsorship, and health information and warnings. This paper analyzes the extent to which tobacco use prevention policies in Cameroon align with the WHO tobacco "best buy" interventions. It further explores the context, content, formulation and implementation level of these policies. METHODS: This was a case study combining a structured review of 19 government policy documents related to tobacco use and prevention, in-depth interviews with 38 key stakeholders and field observations. The Walt and Gilson's policy analysis triangle was used to describe and interpret the context, content, processes and actors during the formulation and implementation of tobacco prevention and control policies. Direct observations ascertained the level of implementation of some selected policies. RESULTS: Twelve out of 19 policies for tobacco use and prevention address the WHO "best buy" interventions. Cameroon policy formulation was driven locally by the social context of non-communicable diseases, and globally by the adoption of the WHO Framework Convention on Tobacco Control. These policies incorporated at a certain level all four domains of tobacco use "best buy" interventions. Formulating policy on smoke-free areas was single-sector oriented, while determining tobacco taxes and health warnings was more complex utilizing multisectoral approaches. The main actors involved were ministerial departments of Health, Education, Finances, Communication and Social Affairs. The level of implementation varied widely from one policy to another and from one region to another. Political will, personal motivation and the existence of formal exchange platforms facilitated policy formulation and implementation, while poor resource allocation and lack of synergy constituted barriers. CONCLUSIONS: Despite actions made by the Government, there is no real political will to control tobacco use in Cameroon. Significant shortcomings still exist in developing and/or implementing comprehensive tobacco use and prevention policies. These findings highlight major gaps as well as opportunities that can be harnessed to improve tobacco control in Cameroon.

Decentralization of HIV care in Cameroon: increased access to antiretroviral treatment and associated persistent barriers.

CONTEXT: The national antiretroviral treatment (ART) program in Cameroon has reached one of the highest rate of coverage in Western and Central Africa (58% of the estimated eligible HIV-infected population in June 2008). OBJECTIVES: To assess the extent to which decentralized delivery of HIV care at the district level has contributed to increased access to ART. METHODS: Comparison of ART-treated and non-ART-treated in the sub-sample of medically eligible HIV-positive patients (n=2566) in the cross-sectional ANRS-EVAL survey was carried out among patients seeking HIV care in 14 hospitals at central level (Yaoundé, Douala and capitals of 8 provinces) and 13 at district levels. Logistic regressions and multivariate analysis were carried out to identify factors related to non-access to ART at both levels of care. RESULTS: Only 7% of eligible patients did not have access to ART. After adjustment for time since initial HIV diagnosis and CD4 counts (at initiation of treatment for those ART-treated and at time of survey for those who were not), younger and male patients, as well as those who only had a primary level education were less likely to be ART-treated at central but not at district level, whereas those who were unemployed were less likely to be treated at both levels. Patients were less likely to be treated in central hospitals with higher workload per medical staff member and absence of task shifting policy, and in district hospitals with non-availability of equipment for CD4 counts and larger size (150 beds or more). CONCLUSION: Main persisting barriers in access to ART in Cameroon are rather due to insufficient access to HIV testing and difficulties in patients' referral to ART delivery centers after HIV diagnosis, since the overwhelming majority of eligible patients already seeking HIV care had effective access. However, health systems strengthening (HSS) is still needed to overcome some remaining barriers in access to ART and to guarantee its long-term sustainability.

Factors influencing the performance of routine immunization in urban areas: A comparative case study of two cities in Cameroon: Douala and Yaoundé.

Urban areas are often omitted from investigations on immunization because the published literature tends to focus on rural settings. The two largest cities in Cameroon - Douala and Yaoundé - are the main drivers of the high number of unvaccinated children in Cameroon. The objective of our study was to identify the factors influencing vaccine incompleteness in Douala and Yaoundé in children (12-23 months of age). We conducted a community-based cross-sectional study using concomitant mixed methods (qualitative and quantitative) with an explanatory aim. The study was conducted in three health districts in each city between March and April 2016. The number of nonvaccinated and incompletely vaccinated children was higher in Yaoundé (3.1% and 40.3%, respectively) than in Douala (0.7% and 10.1%, respectively). The most frequent reason for nonvaccination was related to the parent/guardian not knowing the consequences of not being vaccinated and lack of money. According to the explanatory model, nonvaccination in both cities was associated with the following issues: (1) perceived high visibility of the health district office in terms of vaccination, (2) the shortage of health personnel in immunization centers, (3) attending a private health facility, (4) average or poor behavior of health personnel at immunization centers, and (5) poor knowledge of vaccine-preventable diseases. This mixed-methods study illustrates how inadequacies of the health district framework within urban areas are fueling poor performance of routine immunization in Cameroon. Further research should inform the development of community-centered vaccination services that are most needed, especially in rapidly urbanizing sub-Saharan Africa.

Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: Individual and healthcare supply-related factors.

In low-income countries, health system deficiencies may undermine treatment continuity and adherence to antiretroviral therapy (ART) that are crucial for the success of large-scale public ART programs. In addition to examining the effects of individual characteristics, on non-adherence to ART and treatment interruption behaviors - i.e. treatment interruption for more than 2 consecutive days during the previous 4 weeks, this study aims to extend our knowledge on the role played by healthcare supply-related characteristics in shaping these two treatment outcomes. These effects are examined using multilevel logistic models applied to a sub-sample of 2381 ART-treated patients followed-up in 27 treatment centers in Cameroon (ANRS-EVAL survey, 2006-2007). Multivariate models show that factors common to both non-adherence and treatment interruption include binge drinking (at the individual-level) and large hospital size (at the healthcare supply-level). Among the individual factors, financial difficulties of paying for HIV-care are the major correlates of treatment interruption [Adjusted Odds Ratio (AOR) 95% confidence interval (CI) = 11.73(7.24-19.00)]. By contrast, individual factors associated with an increased risk of non-adherence include: having a main partner but not living in a couple compared to patients living in a couple [AOR(95%CI) = 1.51(1.14-2.01)]; experience of discrimination in the family environment [AOR(95%CI) = 1.74(1.14-2.65)]; a lack of regular meals [AOR(95%CI) = 1.93(1.44-2.57)], and switching antiretroviral drugs (ARV) regimen [AOR(95%CI) = 1.36(1.08-1.70)]. At healthcare facility-level, the main correlate of ART interruption was antiretroviral stock-outs [AOR(95%CI) = 1.76(1.01-3.32)] whereas the lack of psychosocial support from specialized staff and lack of task-shifting to nurses in medical follow-up were both associated with a higher-risk of non-adherence [respective AOR (95%CI) = 2.81(1.13-6.95) and 1.51(1.00-3.40)]. Results reveal different patterns of factors for non-adherence and treatment interruption behaviors. They also suggest that psychosocial support interventions targeted at the individual patient-level will not be sufficient to achieve favorable treatment outcomes if not combined with interventions focused on strengthening health systems, including appropriate drug supplies and human resources policies, as well as sustainable and equitable financing mechanisms.

Higher risk of unsafe sex and impaired quality of life among patients not receiving antiretroviral therapy in Cameroon: results from the EVAL survey (ANRS 12-116).

OBJECTIVE: Cameroon has initiated a national programme of HIV care decentralization providing access to antiretroviral therapy (ART) for patients with CD4 cell counts less than 200 cells/microl or AIDS stage. Current clinical research suggests these criteria may be too stringent. This study aimed at evaluating the effect of not receiving ART on patients' psychosocial outcomes. DESIGN: The national cross-sectional survey EVAL (ANRS 12-116) collected psychosocial and clinical data for 3151 patients attending HIV services (September 2006 to March 2007). METHODS: Propensity score matching was used to control for demographic/clinical-immunological differences between patients receiving ART and those who did not. Generalized linear models were used to assess the impact, for different CD4 cell levels, of "not receiving" ART on health-related quality of life (HRQoL) inconsistent condom use with a sexual partner either serodiscordant or of unknown HIV status, self-reported symptoms and disclosure of HIV status to relatives or friends. RESULTS: Seventy-eight per cent of patients included in the survey were receiving ART. Non-treated patient breakdown was as follows: 8% (CD4<200 or AIDS stage), 5% (200350). In the multivariate matched-pairs analysis, impaired physical HRQoL, more frequent inconsistent condom use, more self-reported symptoms and less frequent disclosure of HIV status were all significantly associated (P < 0.0001) with not receiving ART, irrespective of the CD4 cell level. CONCLUSION: In addition to increasing clinical effectiveness, earlier initiation of ART at less severe immune-depression levels than previously recommended by World Health Organization guidelines for low-resource settings may be justified for improving subjective health and positive prevention among people living with HIV.