Study design and setting
This multicentric cross-sectional study was conducted over a period of 4 months from February 2019 to May 2019 in Cameroon. Three state-owned haemodialysis centres were selected (convenience): the Yaounde General Hospital (YGH), Bamenda Regional Hospital (BaRH), and the Buea Regional Hospital (BRH) haemodialysis centres. The Bamenda and Buea regional hospitals are second-level hospitals located in the North and South West regions of the country, respectively, whereas the Yaounde General Hospital is a fourth-level hospital located in the capital city of Cameroon, precisely in the Center region. All three facilities are government funded and offer a twice-weekly dialysis program of 8 h per week. The 3 centers are all managed by nephrologists.
In Cameroon, out-of-pocket payments account for the majority of health-care financing. Since 2002, the government has subsidized haemodialysis sessions in public-sector centres. Patients are charged XAF 5000 ($ 7.79) per haemodialysis session. This price excludes the costs of vascular access, laboratory tests, medication, feeding, transportation, hospitalization, and vaccination. All of these extra expenditures are borne by patients and their families.
Study participants and procedure
We included consenting participants on maintenance hemodialysis (MHD) for at least 3 months and excluded patients with cognitive impairment or cancer and those unable to communicate verbally or to complete the interview. Patients were met on the day of their dialysis and at the dialysis center. Face-to-face interviews using a questionnaire were conducted either during the haemodialysis session or in the waiting room.
Sample size calculation
Sampling was consecutive and exhaustive. The sample size estimation was based on Bahall’s prevalence in Trinidad , and the online Sample Size Calculator software was used. The minimum sample required was n = 167 to have a confidence level of 90% and a margin of error of 5% of the surveyed value.
A prestructure questionnaire was designed for this study. This questionnaire contains 2 main sections: a sociodemographic and clinical section and a section on CAM use. The patient’s case file was used to complete the section pertaining to the sociodemographic and clinical information. For the cultural area of origin, participants specified whether they were from grassfield (found in the northwestern and western regions), soudano-Sahel (found in the Far-North, North and Adamawa regions), coastal (found in the littoral and southwestern regions), forest (found in the Central and southern regions) backgrounds or nonnationals. Other sociodemographic and clinical information collected included age, gender (male and female), religion (Christian, Muslim, atheist, and other), marital status (single, married, divorced, and widowed), level of formal education (none, primary, secondary and tertiary), comorbidities, aetiology of ESKF, actual treatment and duration of haemodialysis. For the use of CAM, we were interested in the nature and forms of CAM used, the sources of information and procurement, the reason for utilization, and disclosure of CAM use to the treating physician.
Independent variables were sociodemographic characteristics (age, sex, marital and educational status), the presence of comorbidities, aetiologies of ESKF, duration of haemodialysis, use of CAM, modalities of CAM used, reasons for CAM use, and disclosure of CAM use to the treating physician. Dependent variables were the prevalence of CAM use, and factors associated with CAM use among haemodialysis patients.
The data on patient sociodemographics and disease-related information were collected from the patient’s case files, while the knowledge of CAM and its use by the participants were assessed using a face-to-face interview. All cases were identified by the code number. The information collected was based on the PROFORMA checklist. These data were entered into the Census Survey Processus (CSPro version 7.2) system.
Data entered into the CSPro version 7.2 system were exported to the Statistical Package for Social Sciences (SPSS) version 23.0 software for statistical analysis (descriptive and inferential analysis). The descriptive methods included frequency distribution, tables, and graphs. Binary logistic regression was used to identify the predictors of CAM use in the study population based on significant associations identified from sociodemographic variables. All hypotheses were tested at the 5% level of significance. Analysed data are presented as odds ratios (ORs), 95% confidence intervals (95% CIs), and p-values. For multiple logistic regression, only variables with p-values < 0.20 or any clinically significant factor were selected for multiple logistic regression analysis.
Definition of terms
Complementary and alternative medicine (CAM) was defined as any health-related practice that was not prescribed by a medical doctor and not considered conventional medicine.
The modalities of CAM therapies are classified into four categories as in Zakaria et al’s study . These are divided into biologically based therapies, manipulative body-based therapies, mind-body interventions, and alternative medical systems. Biologically based therapies included plants and plant extracts (garlic, ginseng, aloe vera, moringa, green tea, ginger, guava leaves,etc.), geophagic naturally occurring minerals (Calabar chalk), dietary supplements (vitamins B and D) and animal-derived products (honey, eggs). Herbs are defined as any plant part that is used as medicine in any form (leaves, stems, roots, herbal teas, fruits except fruit juices). We are considered as manipulative and body-based therapies, the scarification and massage. Meditation, prayer, fasting, anointed water/oil/bracelets/stickers/cross, sacrifices, music therapy, holy water, exorcism, and burning of incense were considered mind and body interventions. We defined music therapy as regular, intentional listening to music for relaxation and general well-being. We considered as folk/indigenous medicine, the magic, divination, and sacrifices to deities done for health purposes. The level of education was divided into 4 categories: none (for those who had never been to school), primary (for those who interrupted their primary schooling), secondary (for those who interrupted their secondary schooling) and tertiary (for those with university studies).