Nurse-led care for epilepsy at primary level in a rural health district in Cameroon

Authors


Epilepsy is a common serious neurological disorder and is also one of the most frequent of noncommunicable diseases (NCD). It is estimated that over four-fifths of the 50 million individuals with epilepsy in the world are found in developing countries (Scott et al., 2001). Treatment gap figures in developing countries suggest that in places, up to 90% of patients with active epilepsy are not receiving anticonvulsant therapy, and cost is only one of a number of reasons (Scott et al., 2001). Improvement in the medical care of individuals with epilepsy lies with many factors, including improvement of management skills of health care personnel at the primary care level. Empowering trained health workers has been recommended as a means of improving access to epilepsy care at primary health care levels. This approach has been piloted with some measure of success in a number of countries in sub-Saharan Africa (SSA), including Kenya (Feksi et al., 1991), Tanzania (Jilek-Aall & Rwiza, 1992), and Malawi (Watts, 1989). We are not aware of similar initiatives in Cameroon. In addition, previous studies in SSA focused on trained rural physicians and did not assess the feasibility of using only trained nurses for the management of epilepsy. This information would be particularly important for rural SSA, where nurses might be more available than physicians.

The overall goal of the essential NCD health intervention project (ENHIP) was to contribute to strategies for the effective control and prevention of common NCDs within SSA (Unwin et al., 1999). The program in Cameroon was implemented in the capital city (Yaounde) and in the rural health district of Bafut, a region situated about 285 miles to the northwest of Yaounde with an estimated (in 1999) population of 74,750 individuals. In this same year, two medical doctors and over 25 nurses were available in the health district. As part of the ENHIP study, we set up and implemented a nurse-led structured management protocol for epilepsy in the rural health district of Bafut (from 1998 to 2000). The study was designed as a prospective, nonrandomized interventional program of 22 months' duration. International guidelines (Shovron et al., 1991) were adapted to the local circumstances; four nurses were trained and two clinics were set up (one in the public and one in the private sector). Phenobarbital and phenytoin were the main prescribed drugs, with phenobarbital as the preferred first line medication. Treatment decisions were made on an individual basis, taking into account the clinical circumstances of the patient. Dosage charts were available for children and adults. Nurses were authorized to prescribe; however, physicians were also available as needed for advice. During a baseline survey conducted in February 1998, 66 patients with epilepsy (survey patients) were screened and referred to the clinics. A further 158 patients (new patients) were subsequently attracted to the clinics.

Comparison of baseline characteristics between the groups of participants was performed using Student t-tests and chi-square tests and equivalents, as appropriate. Cox regression analysis was used to identify baseline predictors of outcomes during follow-up. All calculations used SPSS (SPSS, Chicago, IL, U.S.A.) 14.0. A p-value <0.05 was considered significant. At the final evaluation, 224 patients (47.3% men) were registered in the two clinics. The median age was 23 (range of 5–72) years. The known duration of epilepsy (71 patients) ranged from 0 to 55 years (median 4), and the average age at clinical onset of the condition was 15 years (Table 1). The average number of days free of epileptic seizures over the month prior to the baseline evaluation was 27.87 ± 4.72 days, with no difference by subgroup. The duration of follow-up was 2,024 patient-months; the follow-up data come primarily from 186 (83%) patients who attended at least one other visit after the baseline evaluation. Six patients (2.7%) died during the follow-up period; no baseline variable was associated with the risk of death. During follow-up, there was a significant downward trend in the number of days per month with seizures in the overall cohort and among subgroups (Fig. 1, all p < 0.024,). Seizure control was poorer among patients in the private clinic.

Table 1.  Baseline variables
VariableMenWomenp-valueTotal
Frequency106 (47.3%) 118 (52.7%)  224 (100%)  
Age (years) 
 Median (range)23.5 (6–72)  22.0 (5–71)  0.1823.0 (5–72)  
 Age groups 0.12 
  <1516 (15.1%)24 (20.3%) 40 (17.9%)
  16–2022 (20.7%)33 (28%)   55 (24.6%)
  21–2525 (23.6%)19 (16.1%) 44 (19.6%)
  26–3014 (13.2%)15 (12.7%) 29 (12.9%)
  31–4010 (9.4%) 17 (14.4%) 27 (12.1%)
  >4019 (17.9%)10 (8.5%)  29 (12.9%)
Source of participants 0.38 
 Baseline survey28 (26.4%)38 (32.2%) 66 (29.5%)
 New case78 (73.6%)80 (67.8%) 158 (70.5%) 
Known duration of the disease 
 Available for31 (29.2%)40 (33.9%) 71 (31.7%)
 Median duration (range), years4 (0–55) 4 (0–41)0.954 (0–55)
Distribution in the two clinics 0.50 
 Public sector60 (56.6%)61 (51.7%) 121 (54%)   
 Private (confessional) sector46 (43.4%)57 (48.3%) 103 (46%)   
Figure 1.


Evolution of the average number of days with fits over the month prior to the visit, for the median number of visits attended during follow-up: overall (upper left panel), by origin of the patients (upper right panel), by clinic of follow-up (lower left panel), and by sex (lower right panel).

This study has provided evidence in support of the feasibility of protocol driven, nurse-led care for epilepsy in rural Cameroon. The program attracted over two times more new patients than those referred for the baseline survey. During follow-up, there was a significant trend toward improvement of patients, as assessed by the reduction in the number of seizures per month, although some patients died and others were lost to follow-up. Experience with primary care models for epilepsy has been reported for some African countries (Feksi et al., 1991), as well as countries outside of Africa (Placencia et al., 1993; Ridsdale et al., 1997; Mani et al., 2001; Wang et al., 2006). In a study similar to ours, the International Community-based Epilepsy Research Group (ICEBERG) investigators in Kenya found that a primary health care worker-led program was effective in achieving seizure-free status or reducing the number of seizures among patients with epilepsy (Feksi et al., 1991). However, in the absence of electroencephalographic (EEG) evaluation in our cohort, it remains difficult to ascertain the extent to which the clinical absence of seizures would translate into a normal EEG. Other limitations to this study include the absence of some types of baseline information, particularly the known duration of epilepsy for most participants, the information needed to classify epilepsy type, and the availability of paraclinical investigation (including EEG). The duration of the program was relatively short, in order to implement the study algorithm in full (particularly as concerns treatment discontinuation). This study, however, adds to the existing knowledge by indicating that nurse-led protocol driven care for epilepsy is feasible and effective in SSA, and that it is worth implementing in settings where physicians are not available to care for such patients. Additional support, through subsidies for medication, will be needed to ensure the success of such an initiative. Clinical trials are needed to assess the efficacy of such an approach as opposed to the usual epilepsy care provided by physicians at primary levels.

Acknowledgments

This study was funded by a research grant from the U.K. Department for International Development (DfID). We thank our collaborators from the University of Newcastle and the nurses in charge of the NCD clinics Manji and Nsem in Bafut.

Conflict of interest: We confirm that we have read the Journal's position on issues involved in ethical publication and confirm that this report is consistent with those guidelines. Authors have no conflict of interest.

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