Improved retention rates with low-cost interventions in hypertension and diabetes management in a rural African environment of nurse-led care: a cluster-randomised trial

OBJECTIVE To compare the effects of low-level facility-based interventions on patient retention rates for cardiovascular (CV) disease in an environment of task shifting and nurse-led care in rural health districts in Central Cameroon. METHODS This study is an open-label, three-arm, cluster-randomised trial in nurse-led facilities. All three groups implemented a treatment contract. The control group (group 1) had no additional intervention, group 2 received the incentive of 1 month of free treatment every forth month of regularly respected visits, and group 3 received reminder letters in case of a missed follow-up visit. The primary outcome was patient retention at 1 year. Secondary outcomes were adherence to follow-up visit schemes and changes in blood pressure (BP) and blood glucose levels. Patients' monthly spending for drugs and transport was calculated retrospectively. RESULTS A total of 33 centres and 221 patients were included. After 1 year, 109 patients (49.3%) remained in the programme. Retention rates in groups 2 and 3 were 60% and 65%, respectively, against 29% in the control group. The differences between the intervention groups and the control group were significant (P < 0.001), but differences between the two intervention groups were not (P = 0.719). There were no significant differences in BP or fasting plasma glucose trends between retained patients in the study groups. Average monthly cost to patients for antihypertensive medication was (sic) 1.1 +/- 0.9 and for diabetics (sic) 1.2 +/- 1.1. Transport costs to the centres were on average (sic) 1.1 +/- 1.0 for hypertensive patients and (sic) 1.1 +/- 1.6 for patients with diabetes. CONCLUSIONS Low-cost interventions suited to an environment of task shifting and nurse-led care and needing minimal additional resources can significantly improve retention rates in CV disease management in rural Africa. The combination of a treatment contract and reminder letters in case of missed appointments was an effective measure to retain patients in care.