Sociocultural Perceptions, Therapeutic Practices of Hypertension and its Management in Bamenda, Cameroon

Sociocultural Perceptions, Therapeutic Practices of Hypertension and its Management in Bamenda, Cameroon

TEBAH Monica ABOH^* & SOCPA Antoine

Department of Anthropology – FALSS, The University of Yaounde I – Cameroon

^*Corresponding Author

DOI: https://dx.doi.org/10.47772/IJRISS.2024.809028

Received: 25 July 2024; Accepted: 10 August 2024; Published: 28 September 2024

ABSTRACT

Hypertension amongst other diseases is a current social and medical problem in Bamenda. People’s perception of the etiology of hypertension, vary and thus influences their therapeutic options (modern medicine and alternative medicines).  Government efforts have been made in the years past to curb the prevalence and improve on the management; these efforts seemed to have been insufficient because the prevalence of the condition keeps increasing despite the government efforts which have always been tilted towards modern medicine. Thus, this study seeks to explore the various healings ways in which the people of Bamenda take care of hypertension.

The main research question is what are the perceptions, and therapeutic practices of hypertension and its management in Bamenda? Subsequently, the main research hypothesis is that the therapeutic practices against hypertension and its management are determined by social representations on this disease. Obviously, the main research objective is to provide an understanding on how people in Bamenda perceive hypertension, and how it is equally managed. Qualitative research data collection and analysis methods were used. Research techniques used were direct observation, individual in-depth interview, focus group discussion, life history, and secondary data analysis. In addition, theories of Functionalism and Critical Medical Anthropology were used to interpret the results obtained after data analysis.

Results from the field revealed that:

• Many newly diagnosed patients of hypertension are ‘initiated’ into drugs too early without proper checkup; also that many patients’ minds are not psychologically prepared that the drugs they are being initiated into will be for a very long time or even for life. In addition, field findings showed that, if the predisposing factors of hypertension in the lives of patients are well handled, they could discontinue drugs with stable BP ;
• Management of the disease by biomedical health care providers is still a great challenge, since patients do not adhere to instructions, leading to hypertension related complications;
• Incorporating the study of non-communicable diseases into the secondary and high school curriculum could improve hypertension management. Educating the population of Bamenda and the North West Region is the key to reducing the prevalence and improving the management of the condition. Thus, education of the population is crucial to reducing the prevalence of the disease and its control.

Keywords: Hypertension, Management, Perception, Sociocultural, Therapeutic practices, Bamenda, Cameroon.

INTRODUCTION

The present study on “Sociocultural Perceptions and Therapeutic Practices of Hypertension and its Management in Bamenda, North West Region of Cameroon”’ explores how inhabitants of Bamenda perceive hypertension and how they make use of the various therapeutic avenues available. Hypertension is defined as the elevation of the blood level from the normal range which is 120/80mmHg to 140/90mmHg and above. Hypertension is often referred to as a silent killer disease because people develop the condition without knowing since there are no visible signs and symptoms. Thus, knowledge of the disease is obtained after the patient goes to the hospital to complain of something else, and he or she is diagnosed as having developed the condition.

Sometimes, diagnosis is done when there are already complications and if the complications are not well handled, it could lead untimely to premature death. Known related complications of the disease include liver problems, heart attack, stroke, heart failure, kidney problems, eye problems, changes in memory understanding, etc. Causes of hypertension range from lifestyle, hereditary, weight gain, and other predisposing factors, and globally, the condition has way over 1.2. billion people who live with hypertension.

They are two major types of hypertension:  primary or essential hypertension which is not related to any condition and secondary hypertension which has been caused by another health condition. Other variants of this “silent killer” disease include resistant hypertension, isolated systolic hypertension, and white-collar hypertension. By unraveling sociocultural perspectives and therapeutic practices, our study contributes to global health discourse and informs strategies for better hypertension management.

GENERAL OVERVIEW OF THE STUDY CONTEXT

Here, we present the situation of Hypertension at the global, African and Cameroon contexts.

• Global Context of Hypertension

Globally, hypertension has remained a health burden for over two decades, and currently has a prevalence of in 2019 that stood at 32% in women and 34% in men with an average prevalence of 33%. This value is projected to be 29% by 2025. More recent values in 2023 by WHO showed that 1.28 billion people live with hypertension from 30-79 years old. 46% are unaware they have the disease. It is a major cause of premature death worldwide. The burden of hypertension compounds existing challenges, especially during the COVID-19 pandemic. Heart disease and stroke, both linked to hypertension, top the list of global causes of death. This health issue transcends race, nationality, and social class, affecting people of all ages. (Matthew R .A. et al, 2019). In 2017, over 60% of the global disease burden resulted from NCDs, including hypertension. Communicable diseases accounted for 28% of the burden (Max R, Hannah  R. 2017).

• Hypertension in African Context

In Africa, hypertension stands as a significant health burden, second only to the HIV/AIDS epidemic that emerged in recent years. Studies indicate that the prevalence of hypertension across the continent hovers around 30%, with a slightly higher rate of 31.1% in the Sahara region (William K.B et al., 2018). However, these numbers only scratch the surface. Despite its impact on older adults, adequate attention to cardiovascular disease management remains insufficient. The cultural context plays a crucial role, as patients develop coping mechanisms and beliefs to improve their condition.   By understanding the complexities of hypertension and its impact, we can develop effective strategies for prevention, management, and improved public health outcomes.

• Hypertension in Cameroon Context

In Cameroon, the prevalence of hypertension varies significantly across different settings. Rates range from 5.7% in rural areas to 21.9% in semi-urban regions and a staggering 47.5% in urban centers. The national average prevalence stands at 31% (Walters T. A., et al., 2016). In the study area which is Bamenda, there’s a huge gap of extensive anthropological research on hypertension. A biomedical study conducted at the Bamenda Regional Hospital in 2017 revealed an intriguing trend. People on highly active antiretroviral therapy (HAART) for HIV had a higher prevalence of hypertension than those not on HAART (Pepanze J. P. et al., 2017).

This dual burden managing both HIV and hypertension—poses unique challenges. Prevalence continues to rise, but awareness and effective control remain low and are even declining. Health care providers in Bamenda grapple with this growing burden, although precise statistics are lacking.  In their article, they saw that knowledge of the condition in this locality is poor as well as compliance rate. (Bentley M.A, et al, 2017).  Compliance rate being low still indicates that at the level of control and management, much more research is needed. By understanding the cultural nuances, health systems, and patient experiences, we can develop context-specific interventions to address hypertension effectively.

RESEARCH METHODOLOGY

This research is located in the field of Medical Anthropology. So, qualitative data collection and analysis techniques were used to explore an in-depth understanding of the complex forces that shape the management of hypertension amongst the people of Bamenda.

A research design constitutes a series of guides which orientate the researcher in her work. The fieldwork started by a pretest for two weeks in December 2021, which led to data collection in 2022 and 2023. The study design was purely exploratory, descriptive, explanatory, analytical and interpretative in nature. Explanatory research design was used for the verification of hypotheses and to examine the relationships between the various variables. The study design comprised of sampling, techniques, field work and language procedures. All these were used for the gathering of data. It was equally used for data processing and analysis.

Emphasis was laid on a sampling which enabled the identification of the informants who are knowledgeable on the topic of research. The cluster sampling method was used to select the representative hospitals in Bamenda. At least, a hospital each from the Bamenda 1, Bamenda 2, and Bamenda 3. Random sampling used to select informants at the hospital. Snow ball sampling used to select Naturopaths/Herbalists in Bamenda.

40 participants were interviewed to understand socio-cultural and therapeutic practices of hypertension. The sample size comprised 20patients, 5medical personnel, 5herbalists or naturopaths, 5faith based organization and 5Community and caregivers. This sample size is chosen to ensure manageability and depth of analysis while still capturing diverse perspectives. Participants were selected to represent a range of ages, genders, and socio-economic statuses to provide a comprehensive understanding of the community’s practices and beliefs. Primary data collection methods used include focused group discussion, in-depth interview, formal interview and life histories. Secondary data analysis was also done. Most of the documents were gotten from hospital records of the Bamenda Regional Hospital, Baptist Hospital Bamenda, Nkwen District Hospital, Bamenda, Faculty of Health Sciences library of the University of Bamenda, the Library of Catholic University Bamenda and the Bamenda City Council Library, Library of University of Yaoundé I, etc.  Audio visual sources also provided us with more data. That was done through watching health programs and listening to health programs over the television and radio, as well as health conferences especially those related to Cardio Vascular Diseases

To conduct this research, we obtained administrative authorization from the University of Yaounde I and an ethical clearance from the Regional Delegation of Public Health of the North West Region.

RESEARCH RESULTS

The results of this study are based on findings we finally came up with during data analysis. These results range from the causes of hypertension to challenges in managing the condition by patients and health personnel. For the sake of this study, we will leave out the aspects of herbalists / naturopaths and faith based organization for a different article.

• Causes of Hypertension

The causes of hypertension are attributed to many different things according to various classes of people. Bio-medically causes are attributed to lifestyle, and hereditary whereas others causes linked to cultural beliefs.

• Lifestyle as perceived cause of Hypertension

There are so many predisposing factors under life style that cause hypertension. They range from food type, to smoking, overweight, to stress, etc. Let us examine a few;

• Stress

Amongst Many informants interviewed, stress related activities led them to developing the condition. Some developed the condition from stressor factor related to family matters, where the load of the family rested on him or her. A lady recounted a story how that for eight years she had been taking care of her house alone There was so much for her to be doing, she had a husband who was not working not because of any fault of his, she had IDPs in the house who did not follow the way of life in that house, yet she was responsible for the tuition and upkeep of both her 4 biological children plus the 2 IDPS in feeding and medical bills. With the limited resources she made at the end of each month, they barely struggled to survive and made ends meet. All of that gave her so much stress. She only discovered herself one day at the hospital and was finally diagnosed of the condition.

What pained me and stressed me up so much was that my husband was not willing to look for a new job after he was retrenched, that gave me so much pain and stress. He cared less about the state of things in the house, house management was entirely my responsibility. More so, the 2 IDPs gave me a lot of headache given that they were 17 years and above. It was when I took seriously ill that hospital told me I was worried about many things and if I was not careful, I would develop hypertension and eventually I became hypertensive. Stress caused me this hypertension. (Claris, 43yrs, 24/5/22 Ntarikon).

There were so many stress related activities that were raised in the cause of the interview. Another woman explained how her daughter had an accident and was not responding to treatment, the next thing she got from the hospital was the fact that, the daughter was going to be operated upon, because her spinal cord was dislocated. The thought of her daughter going through terrible pain led her to developing the condition. She wished she were dead so as not to continue seeing the daughter in severe pain.

Many of the informants who had no family history of the condition reported as follows;

Hmmm, I experienced a lot of stress in my life that I never knew it was causing harm to my system. I was unfortunate in marriage by getting married to the wrong person. This has caused me a lot of pain. My husband gave me no reason to live again on earth. He inflicted pain on me and I bore this pain for long because I was afraid to leave his house because of my faith. It became terrible that I was advised that if I loved my life, then I should leave that house. That was how I left the house very stressed up. It was only when I was sick after I had left him that I was diagnosed of hypertension. I know it was all due to the stress I was going through in his house. Had I know that I could develop this disease, I could have long left his house (Ernestine, 54yrs. Ndamukong Street, Bamenda).

Stress from family matters is diverse, if it is not from husband tormenting wife, it will be from wife tormenting husband, or children tormenting parents, or one parent having it hot from either parent and the children, or in ability for a wife to conceive.

• Anger as a perceived cause

Anger was seen to be another perceived cause to hypertension as raised by informants.  Anger is part of human life, and as long as people live within a cultural context, there are bound to be cultural differences in terms of perception of ideas, interpretation of those ideas, and reactions to those ideas. These perceptions, interpretations and reactions to cultural ideas cause the people of that home or any other cultural environment to get angry. Getting angry is not what provokes the hypertension, but one’s attitudes towards the things that made him/her angry that would cause HTN if it is repeated over time and no positive change of attitude. Life in a cultural setting is full of changes such as death of a loved one, retrenched from work, stubborn children, accident, poor behaviour of a partner etc, all these push some people not only to get stressful but to develop anger and malice which would lead them to be affected health-wise. Below, are some examples of different life situations that made different people to be angry over a long period of life. Amina stated that:

when you vex, when you get problem dem di calculate calculate. Na time way dat high blood go come. Ma own be come start na time way, they be come take ma pikin, then they kidnap ye go because for this crisis (she cries as she thinks of the child that was kidnapped) ..e bi stress me sotehhhh (Amina,  42 years, Mile 4. 19/1/22).

The Muslim lady above said, what caused her hypertension was anger, and when you have many problems that make you to be thinking then HTN will come. She further explained how she developed the condition, her son was kidnapped and never returned she started crying as she explained. She said that kidnapping has kept stressing her, and that caused her to develop the condition. People who get angry too much are liable to developing the condition. Anger causes the blood pressure to rise, and if persistently causing the blood pressure to rise, then such a person is vulnerable to developing hypertension

• Hereditary as a perceived cause of Hypertension

Heredity nature of HTN is cited by both biomedical personal and patients. Let us recount the excerpt from this informant:

Growing up as a young girl, I was already aware that I could develop HTN along the line because both my father/mother had developed HTN, some uncles in the family had also developed the condition. Our parents each time they returned from the hospital would explain to us that, if we were not careful, we would develop the condition like them. So at 16, I had traces that I could develop the condition. I managed the condition until when I was 30 years old when my uncle who was more or less my father died suddenly and that shock sparked the BP to rise. I was taken to the hospital and was also heavy with child. There, they started giving me the treatment because they were afraid I could loss the pregnancy. This is to support the fact that hypertension is also hereditary. (Gladys, 46yrs, Ntabessi, 7/10/2022).

Some patients do not believe the disease is naturally caused. According to some, the disease is a disease of old people. Thus, they are taken aback to see young people who have contracted the disease.

• Supernatural cause of hypertension

Bamenda is a cultural setting just like any other setting with her beliefs and practices. Thus, some patients think the disease could be cause by supernatural means, as the case study below indicates. For a young lady to have contracted the disease, means a supernatural hand is involved.

I do not have any family member sick of hypertension, I am 35 years old, a fat lady. What could have caused my condition. The hospital will say their own, but  I know what am passing through, and I know the kind of family I come from. I belief some family members have a hand in this ( P1, NDH,27/10/2024).

Also, Naturopaths or herbalists think that hypertension is caused by lifestyle, and they do not believe that the condition is caused by heredity. This article is focused on biomedical perspective and another article will be written on herbal perspective.

• Diagnosis/Initiations

Many newly diagnosed patients with hypertension are initiated into drugs too early without proper checkups. It is true that, many patients are diagnosed of hypertension. Some patients revealed to the research team that, they were initiated into drugs immediately they were diagnosed of the condition. One of the patients even complained bitterly that, her father got very angry because the health facility had already placed his daughter on drugs, whereas if the daughter was placed on lifestyle modification, the condition of hypertension could have been managed without being initiated into drugs. He further argued that, the initiation into drugs could have been the last option if lifestyle modification was done and it did not help in controlling the situation.

Initially I had no hypertension and my father is a nurse who was even angry that I was quickly introduced to hypertensive drugs. According to my father, my condition could have been regulated without me taking drugs. For eight years now I have been taking care of the family alone. My husband does not work, I have four biological children and two grown up internally Displaced adults ( Claris  43yrs, 24/5/2022 Ntarikon).

Moreover, concerning initiation, some patients were not comfortable that they had not been properly educated to accept in their minds that the drugs were going to be for life. They got frustrated and helpless to understand that the drugs were going to be taken for a very long time,or it will be life long

• Discontinuation of Drugs with Stable BP

There is a big and ongoing debate amongst health practitioners on the fact that a BP patient can discontinue drugs. This was observed with the younger school of biomedicine and the older school of Biomedicine. The younger school believes that drugs can never be discontinued and that patients are supposed to take them for life. They argued that the BP drugs taken gets into the blood stream of the patients thereby lowering the BP. Thus, when all the drugs in the bloodstream have been used up and no new drugs are being taken, the BP will rise again.

BP is stable because of the drugs. These drugs have a half-life so if the drugs are stopped the BP will rise. So, the patient cannot stop the drugs for they are drugs for life. The drugs can be increased, reduced or others added to it but it cannot be stopped for hypertension is a chronic disease (D1, 5/3/2022 at Bamenda Regional Hospital)

Their older counterparts emphasized that, when the BP levels of patients are normalized, the drugs are reduced. After the reduction, the patients are monitored again over a long period, if the BP still remains normal, the drugs are further reduced. The reduction will continue and monitoring of the patient goes side by side with the reduction. If eventually, the drug is stopped, the patient is monitored and if the BP remains normal, the patient discontinues the drugs but remains under monitoring.

I still today, tomorrow and the next day say no and no and no. don’t make yourself a drug store that’s what I keep telling my patients though I am doing private practice. I will not encourage my patients to make them self a drug store or mobile pharmacy. When you do that you risk your live because if I follow you up on BP and I look at your history on what caused the Bp, if I realize that you are not coming from a family of history of hypertension., BP for instance there are not really treatable per say they are managed, hypertensive issues are managed.  if it were as a result of something that stressed you and push you to it and you realize yourself and you do auto control is ok once it normalizes it is ok. You will not tell the patient that because you started taking drugs you cannot stop without knowing why the hypertension even comes about (D4,28/2/22, Nkwen).

In addition, away from Biomedicine, herbalists and naturopaths believe that hypertension in patients is triggered by something. Thus, if the thing or disease that caused the hypertension is well handled, the BP levels will return to normal.

• Therapeutic Options

Patients’ choices of therapy are influenced by their beliefs, accessibility, and financial resources. They navigate between different therapeutic options based on these factors.

• Self-Medication

Some patients avoid hospitals, religious healers, and herbalists, opting instead for self-medication with plant products. For instance, one informant, Christine, aged 55, has been using plant products since 1985. She visits the hospital only to monitor her vital signs, then returns home to continue her regimen.

Her persistence with plant products suggests a perceived efficacy and relief from their use. Over time, she has started prescribing herbs to local women, effectively becoming a community herbalist. Her treatments include garlics and leaves of “Adam” fruits.

[Pidgin] I no dey go hospital for go take medicine or for control or treatment. ‘garlics and adam fruits and its leaves na tin dem way I de usam for treat myself. She slices 3 pieces of countri garlics every evening and swallows. She takes three garlics because of her   huge size. “na so the German doctor be tell me for di take de garlics. na germans doctors be say make i use only garlics/adam fruits leaves. She does this after much work and not feeling too tire (Christine, 55years, 8/7/21, Bambui).

[English translation] I do not go to the hospital for medicine or treatment. I she uses garlics and Adam fruits and their leaves to treat herself.” She slices and swallows three pieces of country garlics every evening, attributing the dosage to her size and advice from a German doctor. She follows this routine after strenuous work unless she feels fine, in which case she skips the treatment (Christine, 55years, 8/7/21, Bambui).

Despite her claims of not seeking hospital treatment, Christine does visit to check her blood pressure, indicating some level of medical oversight. Her reliance on garlics and “Adam” fruit leaves underscores a blend of traditional and biomedical practices in her health management.

• Hospital Medication or Biomedicine

In Bamenda, when individuals feel unwell, their initial response often mirrors that of other societies: they search their homes for common medications like paracetamol to alleviate symptoms such as headaches. If this proves insufficient, they may purchase drugs from roadside medicine vendors, with only a few opting for recognized pharmacies. The hospital becomes the final resort after other options, including herbal remedies, have failed.

Even when resorting to hospital care, patients may switch between hospitals based on service satisfaction, accessibility, treatment costs, and peer influence. Many patients, once diagnosed, rely exclusively on hospital treatment, citing significant relief from biomedical interventions. This satisfaction fosters a sense of peace, potentially benefiting their blood pressure (BP).

I like the services dem for here because dem di makam my bp di go down. I be improved. I no de too over get dat heartbeat .  Tin way I want say make them improve na sa, when ma high blood go down make dem reduce drugs, when e go up, they fit increase sam. because na so, whether the high blood high or low, the medicine no dey change, I de still buy how way I be di buy. so the tin na di pass me. so I be don even try for tell dem say as the BP di go down, make dem reduce price, woside , they no reduce sam. I be come here ma BP be bi 200, 180, 190. so na I do seyam e go down for 120, 130, I say make dem reduce medicine, they deny (Prudence. Female 62 yrs. 19/1/ 22, Baptist Hospital Nkwen)

The speaker said that she liked the services there because they helped lower her blood pressure. She mentioned that she had improved and no longer experienced rapid heartbeats. She wanted the services to improve by reducing medication when her blood pressure was low and increasing it when it was high. However, she noted that the medication dosage remained the same regardless of her blood pressure levels, which was frustrating for her. She had even tried to tell the staff to reduce the price as her blood pressure decreased, but the staff did not comply. The speaker shared that her blood pressure had been around 200, 180, or 190 when she first arrived, but it had since dropped to 120 or 130. Despite this improvement, the staff refused to reduce the medication.Prudence’s account highlights her satisfaction with the hospital services due to the effective management of her BP, despite her concerns about the inflexibility of medication adjustments.

• Herbal/Naturopathic Remedy/Faith based Organization

For those who believe in herbal remedy, the first thing done is to go behind the house to harvest lemon grass what is commonly called “fever grass”. They boil and drink. They tell you, it will take away the fever.   Normally, if a patient boiled this lemon grass and drank then felt relieved, that was all; he would not go to any other therapy. Often, they do not only move from one hospital to the other, they begin by going to herbalist doctors and faith based organization. This section on Herbal medicine is explained in another article.

Challenges in the Management of Hypertension by Biomedical personnel and patients

Since the onset of hypertension, the health system has been experiencing challenges at all levels. Managing Hypertension in Bamenda is equally very challenging, and the ongoing crisis in the region has exacerbated the challenges faced by biomedical healthcare providers as well as the patients in managing hypertension (HTN). These challenges are multifaceted, encompassing both pharmacological and non-pharmacological aspects.

• Challenges faced by Biomedical Personnel

The primary difficulty in managing HTN lies in the need for a complementary approach between pharmacological and non-pharmacological treatments. Effective management requires both to work in tandem. However, patients often discontinue medication once they feel better, only to return to the hospital with complications when symptoms reappear. This discontinuity poses a significant challenge.

Even those who have drugs do not follow the prescribed schedule. You tell a client to take their medication in the morning, but they take it in the evening instead. For those who smoke or drink alcohol, despite being warned about the dangers, they continue these habits, thinking they can deceive the doctor. In reality, they are harming themselves (D4, Nkwen 28/2/23)

Dr. D4 elaborated that patients often ignore medical advice, believing they can hide their non-compliance from healthcare providers. This behavior is reflected in their rising BP levels, indicating a lack of adherence to prescribed treatments. Additionally, some patients forget to attend routine check-ups, which could prevent complications if done regularly. This lapse in follow-up care further complicates the management of hypertension. Poor proclamation by traditional healers that hypertension can be cured by them poses a great challenge in managing the disease by health care providers. When these healers make fake proclamations, and patients get to them, and take their concoction for long, it damages their organs without any relief to the patients. By the time these patients get to the hospital, their organs are already damaged.

• Challenges faced by Patients themselves

Moreover, management of the condition to patients poses even a greater challenge for the following reasons:

These patients miss out on appointment dates at the hospital because of the so many days declared immovable that comes on unplanned. This makes patients to go for some days without drugs. Normally, drugs are given to patients during their routine visit for a period of one month, where they will come again and purchase more drugs. Thus, if the drugs got finished and patients unable to reach the hospital on their appointment days, they will eventually go for some days without drugs and this will affect them negatively. They only go after the appointment dates to the hospital.

More so, the challenge of managing hypertension increases with the patients because some of these patients have to quit their residence abruptly due to the instability in this part of the country. Some run away from homes into the bushes forgetting their drugs at home and spend a day or more in the bushes without the drugs. Some equally travel out of their community into a new community and take some little time to adapt. All these pose a challenge to these patients.

Still in line with the above, because of the constant movement, some of them go out of business and become unable to purchase their drugs. Some even developed the habits of skipping days without taking drugs just so that these drugs can last until such a time that they can afford to buy more drugs. Patients even request for help of say 3 or 4 tablets of their drugs from their friends who are also having the condition. This is a practice the hospital is completely against and always discourages during every routine visit.  Yet, others face challenges because of their inability to control themselves. The challenge of patients managing the condition also comes from related complication of hypertension like diabetes as is narrated below by that informant:

Like now way I dey hospital,ma hand dey pain me for here so, only so [She shows where its paining to the researcher], this two hands dem. So I really come today for consult because I get hypertension and I get diabetes too. I want hmmmm ask whether na the HTN dey give me dis pain or na diabetes? na ye makam I dey here today.  For almost eleven years I dey me fine as I dey take my drugs. Na only did time way I be want get stroke. I no ever get me any problem, I dey me fine. Long ghost town affect me plenty because if ma medicine finsih along the line, I dey for problem (Rosaline, 50 years. January 19, 2022. Mbingo Baptist Hospital Nkwen).

The above informant said, right there as she was at the hospital, her hands were hurting—both of them.” She gestured to where the pain was located. She had come for a consultation because she was having hypertension and diabetes. She was wondering whether the pain was due to the hypertension or the diabetes. That’s why she was at the hospital. For nearly eleven years, she has been doing well while taking her medications. It’s only recently that she is been concerned about the possibility of having a stroke. She has never had any other health issues; she had been fine. The extended ghost town periods have affected her significantly because if her medication ran out unexpectedly, she would be in trouble

A young lady of 30 said, when it was discovered that she was hypertensive, it affected the way she started looking at life, she started giving up on certain institution she valued so much like giving up on marriage. She thought with hypertension, one could possibly not get married again, bare children or even further education. She had placed lots of limits to her life.  The research team had to counsel her in addition to all the counsel she had been receiving from the hospital and made her to understand that she could achieve every life dream, all she needed to do was to follow up on the instruction given to her at her health facility by the HCP.  In Bamenda socio-culturally it is strongly held that, hypertension is still considered as a disease for the old, reason why it plays negatively a lot on the younger patients.

Collaboration between Biomedicine and Herbalists/Naturopaths

• Potential for Collaboration

Collaboration between herbalists and biomedical practitioners could be possible if biomedical practitioners do not look down on herbalists. More importantly, collaboration could be facilitated if the government were to seriously get involved in incorporating both sectors.

• Challenges to Collaboration

Biomedical practitioners emphasize that collaboration is not possible because herbalists do not have adequate knowledge to treat hypertension. They argue that the claim by naturopaths/herbalists to be able to cure hypertension, which they know is incurable, further deepens their reluctance to collaborate.

• Diagnostic and Treatment Concerns

Additionally, the means of diagnosis by herbalists is very questionable, not to mention the dosage of the concoctions produced by herbal doctors. Biomedical personnel refute collaboration because they see the herbal sector as negatively affecting the management of hypertension. Despite hospital advice not to take herbal treatments alongside hospital medicine, patients often go ahead and take the concoctions, leading to drug-drug interactions and complications. This poses a major challenge to the management of the condition at the hospital level:

In my own opinion, there can be no collaboration because we discourage traditional medicine.   N1:  Even with the traditional herbs, there dosage is not known. They do not take other things into consideration before administering. If they had the possibility of running their tests, to find out how well the livers, the kidneys are functioning so as to be able to determine the dose, I think it will be somehow. But as we have said, traditional medicine does not work well with conventional medicine. Collaboration between traditional or Naturopaths is not possible (N1/N2. 27/4/2024 at Uba).

• Perspectives on Collaboration

Biomedical practitioners view collaboration as something far-fetched. However, a few believe that collaboration could be possible if herbalists were to undergo formal education and training.

They can collaborate but the problem is to sit together and accept the rules of engagement. It is possible for collaboration but they need to sit and share experiences. The problem is that we do not know the content of the drugs they give however we need to sit have a frank discussion to establish a guide line of management of hypertension if not disorder prevails and is not good for the patients Dr. (D5, 5/03/22 Regional Hospital Bamenda).

Some other health care practitioners also see some diseases that the hospital has not yet been able to cure. The hospital will give so many drugs, but will refer the patient to go home and look for somebody who can prepare them herbal medicine. They confess that, the hospital cannot treat every disease that is why there is need for both sectors to collaborate so that the health sector of the country can be improved.

Improving on Management of Hypertension in Bamenda

If hypertension is properly controlled and managed, it can have a far positive effect in the future and the burden of the disease on public health of Cameroon will be greatly reduced. The Management is in many ways:

• Introduction of Non Communicable Diseases into the School curricular

Firstly, introduction of NCDs into the curriculum of secondary and High School in Cameroon; field findings showed that, if the population begins to have knowledge of what NCDs is all about, how the condition can be prevented, how it can be managed. It will go a long way to improve on hypertension management in this country. Assuming children in secondary schools are properly educated on hypertension and other NCDs, the children will grow up knowing what to avoid or to take in a responsive manner. Those that have a family history of hypertension will be aware and will learn to avoid what caused their hypertension of that family member. They grow up also knowing the importance of physical exercise.

Awareness creation remains key in managing and preventing the condition. Many management centers of hypertension have to be created and many more staff gotten to enhance management of the condition. Unauthorized road store drug dealers have to be brought under controlled because most of them claim to manage hypertension without having any knowledge of the disease. They equally prescribed without knowing effectively, what they are prescribing. This always in the long run leads to a complication making management difficult. Moreover, the young bio-medical doctors and nurses handling NCDs, should always go for refresher training. This will help them to know when to initiate a patient into drugs, what kind of drugs to prescribe and how to handle difficult patients.

• Creation of a WhatsApp Group in the Management of Hypertension: Perspective of the HCPs at the Hospital

The focal point for Diabetes and Hypertension in the Regional Delegation for Public Health fully supported the creation of such a platform, believing it would enhance the management of the condition not only in health facilities but throughout the North West Region of Cameroon. However, she emphasized that it is the responsibility of individual health facilities to create such a platform if they deem it necessary. At the regional level, they do not impose such initiatives, preferring a bottom-up approach rather than a top-down one. The initiative should originate from the health facilities themselves.

While some health facilities saw the creation of a WhatsApp group as a good idea, they felt it was not appropriate at that moment due to their heavy workloads. They expressed concerns that creating such a platform would add to the already substantial workload of the few nurses available. During a discussion with healthcare providers (HCPs) at Baptist Hospital Nkwen on April 27, 2022, at the Health Complex of the University of Bamenda, they shared their views:

Currently, in our unit, we have a WhatsApp group for diabetes. It used to be a combined diabetes and hypertension (HTN) club, but now it is separate. If there is a need for an HTN WhatsApp group, we will create one (Ni/N2 , 36 and 43 years ,  27/4/22, Uba).

The Regional Delegation cannot impose or mandate the creation of WhatsApp platforms on various health facilities. In a conversation with Dr. D1 of the Regional Hospital Bamenda, who is in charge of Non-Communicable Diseases (NCDs), on August 11, 2022, he stated:

Any means that will help manage high blood pressure is welcome. The creation of a WhatsApp group is a good idea. Ideas related to the management of the condition will be shared on the forum for patients to read and watch. This alone will boost the image of the patients (D1, 28 years, 11/8/22, Bamenda Regional Hospital).

The Major of the unit at Bamenda Regional Hospital also supported the idea of a WhatsApp forum. However, she highlighted a significant challenge: many patients were too old and might struggle to manage their Android phones, with some unable to read or write.

DISCUSSIONS OF THE RESULTS

From the research results, causes of hypertension are attributed to various factors according to our informants. Biomedically, the etiology of this disease is linked to lifestyle and hereditary factors whereas in the community, hypertension is associated with sociocultural factors

Biomedical etiology of Hypertension

Amongst many informants interviewed, stress-related activities led them to develop the condition. Some developed hypertension due to stressors related to family matters, where the burden of the family rested on them. For example, a lady called Claris recounted her story of how, for eight years, she had been taking care of her household alone. She had a husband who was not working, not due to any fault of his own, and she had internally displaced persons (IDPs) in the house who did not follow the household’s way of life. She was responsible for the tuition and upkeep of her four biological children plus the two IDPs, including feeding and medical bills. With the limited resources she earned at the end of each month, they barely managed to survive and make ends meet. All of this caused her significant stress. She only discovered her condition one day at the hospital, where she was finally diagnosed with hypertension.

The narratives provided by Claris, one key informant and other informants highlight the significant impact of stress, anger and social role / responsibilities on one’s health. From a functionalist perspective, we can interpret these personal accounts by examining how social structures and roles contribute to the overall stability and functioning of society, and how disruptions in these roles can lead to health issues like hypertension. When these roles are disrupted or become overly burdensome, it can lead to stress and subsequent health problems. From a functionalist perspective, stress as a perceived cause of hypertension can be understood by examining how social structures and cultural contexts influence individual behavior and health outcomes.

• Social Roles and Cultural Context

Anger, as a human emotion, arises from interactions within these social structures and cultural contexts. Differences in perception, interpretation, and reaction to cultural ideas can lead to anger, which, if not managed properly, can contribute to health issues like hypertension. Life in a cultural setting is full of changes, such as the death of a loved one, job loss, dealing with stubborn children, accidents, or poor behavior of a partner. These changes can disrupt the stability of an individual’s life, leading to stress and anger. Functionalism would suggest that these disruptions in social roles and expectations can have negative health implications. For example, Amina’s account of her son’s kidnapping and the resulting stress and anger illustrates how significant life events can impact health. The prolonged stress and anger she experienced due to her son’s disappearance contributed to her developing hypertension. This aligns with the functionalist view that disruptions in social stability can lead to health problems.

Implications for Health Management

In this context, managing hypertension would require not only medical intervention but also addressing the social and cultural factors that contribute to stress and anger. By understanding the role of social structures and cultural contexts in health, healthcare providers can develop more holistic approaches to managing hypertension. This might include providing support for individuals dealing with significant life changes, promoting healthy coping mechanisms, and fostering a supportive community environment.

• Discontinuing drugs with stable BP

Functionalism would examine how the practices of drug initiation and discontinuation serve to maintain social order and stability. We can look at the insistence of life-long drugs by the younger school of thought as indicated by D1 who insisted that drugs serve a lifelong purpose and should not be discontinued as a means to ensure consistent management of hypertension, which would serve further to reduce the risk of potential complications eventually maintaining public health.

On the other hand, the older school’s approach to gradually reducing medication reflects an adaptive strategy that allows patients to integrate their treatment into their daily lives, more conveniently. This approach favors social integration by reducing the burden of lifelong medication and enhancing or promoting a sense of normal life As was reflected in the interview with D4 who emphasized that, human beings were slaves to drugs, and that if the hypertension causing factor is handled and BP is stable under controlled for a long period of time, normal life could be encouraged.

Each therapeutic option (self-medication, hospital medicine, naturopathy, herbalism, and prayer) serves a specific function in the society. These options provide a range of solutions that cater to different beliefs, economic statuses, and accessibility needs, thereby maintaining social stability by ensuring that everyone has some form of healthcare available. The movement from one therapy to another based on satisfaction or dissatisfaction helps individuals adapt to their health needs. This adaptability ensures that people remain integrated within the healthcare system, even if they switch between different types of treatments. It also reflects the society’s ability to accommodate diverse health beliefs and practices, promoting social cohesion. The choice of therapy is influenced by economic factors (available funds) and social factors (peer influence, accessibility). Functionalism would argue that these factors help maintain the equilibrium of the healthcare system by distributing patients across various therapeutic options, preventing any single system from becoming overwhelmed.

The preference for different therapeutic options reflects the cultural beliefs and practices of the people in Bamenda. For instance, the use of lemon grass (fever grass) for treating fever is rooted in traditional knowledge and practices. This cultural practice is passed down through generations and is an integral part of the community’s health-seeking behavior. Patients navigate through various therapeutic options based on their beliefs, experiences, and the perceived effectiveness of treatments. This navigation is a dynamic process influenced by personal and communal experiences with different therapies. It highlights the importance of understanding local health beliefs and practices in providing culturally sensitive healthcare.

The satisfaction or dissatisfaction with a particular therapy influences patients’ trust in that option. This trust is built through personal experiences and community recommendations. When patients find relief from a particular therapy, they are likely to trust and continue using it, reinforcing the cultural significance of that therapy. The choice of therapy is also shaped by accessibility and economic constraints. Patients often start with the most accessible and affordable options (e.g., self-medication, herbal remedies) before moving to more formal healthcare settings (e.g., hospitals) if needed. This progression reflects the practical considerations that influence health-seeking behavior in the community. Thus, therapeutic options in Bamenda are not just medical choices but are deeply embedded in the social, cultural, and economic fabric of the community. This understanding can help healthcare providers offer more effective and culturally appropriate care.

Challenges by Health Care Personnel

Functionalism views society as a system where each part works together to maintain stability and social order. Applying this perspective to the challenges faced by biomedical personnel in managing hypertension (HTN) we consider the following:

• Complementary Approach / Pharmacological and Non-Pharmacological Treatments

Effective management of HTN requires both types of treatments to work together. This reflects the functionalist idea that different components of the healthcare system must work together to maintain overall health and stability. When patients discontinue medication prematurely, it disrupts this balance, leading to complications and increased strain on healthcare resources.

• Non-Adherence to Medication / Patient Behavior

Patients often do not follow prescribed schedules or continue harmful habits like smoking and drinking. This non-compliance can be seen as a dysfunction within the healthcare system, where the intended function of medication is not realized due to patient behavior. This highlights the need for better patient education and adherence strategies to ensure the system functions effectively.

• Routine Check-Ups / Missed Appointments

Patients forgetting to attend routine check-ups poses a significant challenge. Regular check-ups are crucial for preventing complications, and their absence can lead to more severe health issues. This lapse in follow-up care disrupts the preventive function of the healthcare system, emphasizing the need for improved patient follow-up mechanisms. The importance of regular check-ups is emphasized, as missing these appointments can lead to preventable complications.

• Influence of Traditional Healers / Misinformation and Delayed Treatment

Traditional healers claiming to cure hypertension can mislead patients, causing them to delay effective treatment and potentially worsen their condition. This misinformation undermines the healthcare system’s function, highlighting the need for better integration and communication between traditional and biomedical practices.

Implications Challenges by Health Care Personnel

• Healthcare System Efficiency

The functionalist perspective underscores the importance of a well-coordinated healthcare system where pharmacological and non-pharmacological treatments complement each other. Ensuring patient adherence and regular check-ups can enhance system efficiency and prevent complication

• Patient Education and Adherence

Addressing non-compliance requires effective continuous and overly repeated patient education and adherence strategies. Healthcare providers need to emphasize the importance of following prescribed treatments and attending routine check-ups to maintain health and prevent complications.

• Integration with Traditional Practices

The influence of traditional healers highlights the need for better integration of traditional and biomedical practices. Educating patients about the limitations of traditional remedies and the benefits of biomedical treatments can improve overall health outcomes. In summary, from a functionalist perspective, the challenges faced by biomedical personnel in managing hypertension illustrate the need for a well-coordinated healthcare system, effective patient education, and better integration with traditional practices. Addressing these challenges can enhance the overall functioning and stability of the healthcare system.

• Healthcare System Strain

The increase in hypertension cases and the shortage of healthcare staff create a strain on the system. Functionalism would highlight the need for a well-staffed and efficient healthcare system to manage the health of the population effectively. This ensures that the system can handle the demand and maintain societal stability.

• Impact of Crisis

The ongoing crisis in the region exacerbates these challenges. Functionalism would see the crisis as a disruption to the normal functioning of society, affecting both patients and healthcare providers. Ensuring that healthcare services continue to operate smoothly during such times is crucial for maintaining social order and stability. The economic and social barriers that prevent patients from attending appointments or accessing medication need to be addressed. This includes considering the impact of immovable days and the financial burden of healthcare. Anthropologists would advocate for more accessible and affordable healthcare options to ensure that all patients can maintain their treatment regimens. By implication, building community support systems can help patients adhere to their treatment plans. This includes educating patients and their families about the importance of medication adherence and regular checkups and providing support to overcome barriers to healthcare access.

Challenges faced by Patients

Again, Functionalists views society as a system where each part works together to maintain stability and social order. Applying this perspective to the challenges faced by patients in managing hypertension (HTN):

• Missed Appointments / Immovable Days

Patients often miss hospital appointments due to unplanned immovable days, leading to gaps in medication. This disrupts the healthcare system’s function of providing continuous care, highlighting the need for flexible healthcare delivery methods to maintain stability.

• Instability and Displacement /Abrupt Relocation

Patients fleeing instability often leave their medications behind, spending days without them. This reflects a dysfunction in the system where external factors disrupt the continuity of care, emphasizing the need for portable and accessible healthcare solutions.

• Economic Challenges: Financial Instability

Constant movement and loss of business make it difficult for patients to afford medications. This economic instability affects their ability to manage HTN, underscoring the importance of affordable healthcare and support systems to ensure continuous treatment.

• Resource Sharing / Borrowing Medications

Patients borrowing drugs from others indicate a community-based coping mechanism. While this practice is discouraged, it shows how patients adapt to resource scarcity, highlighting the need for better resource allocation and support.

• Comorbid Conditions / Hypertension and Diabetes

Managing multiple conditions like HTN and diabetes adds complexity to patient care. This dual burden requires integrated care approaches to address the interconnected health issues effectively.

Implications of Challenges faced by Patients

• Flexible Healthcare Delivery

The functionalist perspective highlights the need for healthcare systems to adapt to external disruptions. Implementing flexible delivery methods, such as mobile clinics or telemedicine, can help maintain continuous care during immovable days or instability.

• Economic Support and Accessibility

Addressing economic challenges is crucial for ensuring that patients can afford their medications. Subsidized healthcare, financial aid programs, and community support can help mitigate the impact of financial instability on health management.

• Integrated Care Approaches

Managing comorbid conditions requires integrated care approaches that address multiple health issues simultaneously. Coordinated care plans and patient education can improve overall health outcomes.

• Community-Based Solutions

While borrowing medications is not ideal, it highlights the importance of community support in healthcare. Strengthening community health programs and ensuring better resource allocation can help patients manage their conditions more effectively.

Introduction of NCDs into School Curriculum

• Education and Prevention

Introducing non-communicable diseases (NCDs) into the school curriculum ensures that children grow up with knowledge about hypertension and other NCDs. This education helps prevent the onset of these conditions by promoting healthy behaviors from a young age. This aligns with the functionalist view that education serves to maintain social stability by preparing individuals to contribute positively to society.

• Awareness Creation

Creating awareness about hypertension is crucial for its management and prevention. Awareness campaigns and education help individuals understand the importance of regular check-ups, medication adherence, and lifestyle changes. This contributes to the overall functioning of the healthcare system by reducing the burden of hypertension on public health.

• Control of Unauthorized Drug Dealers:

Controlling unauthorized roadside drug dealers ensures that patients receive proper medical advice and medications. This regulation prevents complications arising from incorrect prescriptions and supports the healthcare system’s function of providing safe and effective treatments.

• Refresher Training for Healthcare Providers

Regular training for biomedical doctors and nurses ensures they stay updated on the best practices for managing hypertension. This continuous education helps maintain the healthcare system’s efficiency and effectiveness, ensuring that patients receive the best possible care.

Implications of Improving Management of Hypertension in Bamenda

• Long-Term Health Benefit

Proper management and control of hypertension can significantly reduce the disease burden on public health in Cameroon. Educating the population from a young age and creating awareness can lead to long-term health benefits and a more stable healthcare system.

• Improved Healthcare Delivery

Controlling unauthorized drug dealers and providing continuous training for healthcare providers can improve the quality of healthcare delivery. This ensures that patients receive accurate diagnoses and effective treatments, reducing complications and improving health outcomes.

• Economic and Social Stability

Effective management of hypertension can reduce healthcare costs and improve the overall well-being of the population. This contributes to economic and social stability, as a healthier population is more productive and less burdened by healthcare expenses.

Creation of Whatsapp Group

• Enhancing Communication and Support

The creation of a WhatsApp group can enhance communication and support among healthcare providers (HCPs) and patients. This platform allows for the quick sharing of information, advice, and support, contributing to the overall stability and efficiency of the healthcare system. It ensures that patients receive timely advice and support, which is crucial for managing chronic conditions like hypertension. Moreover, the existence of a WhatsApp group for diabetes management shows that such platforms can be effective. Adapting and integrating similar platforms for hypertension can leverage existing structures and experiences, enhancing the overall management of non-communicable diseases (NCDs). At last, the success of existing WhatsApp groups for diabetes management suggests that similar platforms for hypertension can be effective. Scaling up and integrating these platforms can enhance the management of NCDs, contributing to the overall stability and efficiency of the healthcare system.

• Bottom-Up Approach

The preference for a bottom-up approach, where individual health facilities decide to create such platforms, empowers these facilities to tailor solutions to their specific needs. This decentralized approach ensures that the initiative is relevant and effective, enhancing the functionality of the healthcare system at the local level.

• Workload Concerns

Some health facilities expressed concerns about the additional workload that managing a WhatsApp group might entail. This highlights the need for adequate resources and support for healthcare providers to ensure that such initiatives do not become a burden. Proper resource management is essential for maintaining the efficiency and stability of the healthcare system. Addressing workload concerns requires proper resource allocation and support for healthcare providers. Ensuring that HCPs have the necessary resources to manage these platforms can prevent burnout and maintain the efficiency of the healthcare system.

CONCLUSION

This research, conducted in selected quarters and hospitals in Bamenda, provides a nuanced understanding of the perspectives on collaboration between biomedical practitioners and herbalists in managing hypertension. The findings highlight the complexities and potential benefits of integrating these diverse healthcare practices.

Key Findings

• Causes and Diagnosis: Biomedical practitioners emphasize the importance of accurate diagnosis and understanding the causes of hypertension. They express concerns about the diagnostic methods used by herbalists, which may not align with standardized medical practices.
• Initiation and Discontinuation of Treatment: There is a need for clear guidelines on when to initiate and discontinue treatment. Biomedical practitioners stress the importance of monitoring blood pressure (BP) and adjusting treatments accordingly. They are cautious of herbal treatments that lack standardized dosages and may interfere with conventional medications.
• Potential for Collaboration: Some biomedical practitioners believe that collaboration could be possible if herbalists undergo formal education and training. This could help bridge the gap between traditional and modern medical practices, ensuring that both contribute positively to patient care.
• Challenges to Collaboration: The reluctance to collaborate stems from concerns about the unknown content of herbal drugs, potential drug-drug interactions, and the lack of standardized practices. These challenges highlight the need for clear rules of engagement and mutual respect between practitioners.
• Diagnostic and Treatment Concerns: The need for standardized diagnostic methods and treatment guidelines is crucial to ensure patient safety and effective management of hypertension. Biomedical practitioners emphasize the importance of evidence-based practices to maintain the integrity of the healthcare system.

RECOMMANDATIONS

The Cameroon Ministry of Public Health should take proactive steps to enhance hypertension management by increasing the number of healthcare professionals and establishing more management centers in both urban and suburban areas. This can help ensure that patients have access to reliable and effective treatments. In addition, integrating biomedicine with herbal and naturopathic practices can promote social solidarity and respect for cultural heritage. This integration can lead to a more holistic approach to healthcare, addressing both modern medical needs and traditional practices. At last, to gain a more comprehensive understanding, it is essential to extend the study to other areas and hospitals within Bamenda. Additionally, exploring the role of faith-based organizations in healing practices could provide valuable insights into the diverse approaches to healthcare in the region.

REFERENCES

Books

1. Anita, H. et al. (1995) Applied Health Research Manual. Anthropology of Health and Health Care. Printed in the Netherlands.
2. Blumhagen, Dan, (1980 Hyper-tension. A folk illness with a medical name. Culture, Medicine and Psychiatry
3. Byron J.G, (1994). Medicine, rationality and Experience. An Anthropological Perspective. Cambridge University Press.
4. Delbert, C.M., (2005). Hand book of Social Design and Social Measurement. The International Professional Publisher Newbury, 5^th Ed Sage publication Park London.
5. Garfinkel, H., (1987). Studies in ethnomethodology. New Jersy, Prentice Hall.
6. Gilles, B., & al. (1992) The Social Basis of Health and Healing in Africa. A comparative studies of health Systems and Medical Care. University of California Press, Berkeley 94720.
7. John C.M and Tim E. (2007) The Maxwell Leadership Bible. Sec.Ed.New King James Version, Nashville Dallas, United States of America
8. Kottak C.P., (1991) Anthropology, Exploration of Human Diversity, Mr. Graw-Hill,Inc, New York, St Louis.
9. Mofor, Mofor, E. (2024) Natural Herbal and Preventive Medicine. Vol IV, Revised Edition. A 21^st Century Health Guide for every Home. Shiloh Printers. Bamenda
10. Natasha, M. & al. (2005) Qualitative research Methods: A Data Collector’s Field Guide. Family Health International.
11. Nkwi, P.N et al. (2001) Field Research into Socio-Cultural Issues; Methodological Guidelines. International Centre for Applied Social Sciences, Research and Training (ICASS-RT), Yaoundé –Cameroon.

Dissertation and Thesis

1. Aboh, M.T. (2019) Anthropological Study on the Management of Hypertension in Biyem-Assi, Yaoundé. MSc Dissertation. University of Yaoundé I.
2. Andoseh, C. (2015) Perception Of Hepatitis C Virus In Ebolowa, South Region of  Cameroon : A Contribution To Medical Anthropology. MSc Disertation. University of Yaounde I.
3. Awah, P.K. (2005) Treating Diabetes in Cameroon: A Comparative Study in Medical Anthropology. PHD Thesis. University of Newcastle, UK
4. Tsabang, N. (2008) Ethnobotanical study of plants has antidiabetic properties and/or antihypertensive Cameroon. PHD Thesis, University of Yaounde I.
5. Lawong V.D. (2023) Perception and Treatment of Hepatitis-B in Mezam Community of the North-West Region of Cameroon. PhD Thesis, University of Yaounde 1.

Articles

1. Atashili J. (2010) Epidemiology of hypertension in the Fako Division, Cameroon (Hypertension in the Fako Division, Cameroon: Prevalence and risk factors). http;/bmb.Oxfordjournals.Org/cgi/pmidlookup?view=long&pmid=16148191. Retrieved on 2009-06-21
2. Frank M. S. et al. (2009) A dietary Approach to prevent hypertension: A review of the dietary approaches to stop HTN(DASH)Study. Clinical Cardiology, 22(Supplement 111), 111-6 to 111-10.
3. Frank, L. T, et al, (2018) Prevalence, awareness, treatment, and control of hypertension in Cameroonians aged 50 years and older. A community–based study. First published 27 April 2018.
4. Hackam, D.G et al. (2010). Canadian Hypertension Education Program. The 2010 Canadian Hypertension Education Program Recommendations for the Management of hypertension: part 2 therapy. Can J Cardiol 26:249-258.
5. Naambow , A. E.C,  & SOCPA, A (2021). Ethnological Study of the Perceptions and Representations of Diabetes in Socioculture Yeminkol De Soa, Region of Centre-Cameroon. EAS J Humanit Cult Stud, 3(6), 255-265
6. Walters Tabi A. et al. (2016) Hypertension, an Emerging Problem in Rural Cameroon: Prevalence, Risk Factors, and Control. International Journal of Hypertension, Int J Hypertens. 2016; 2016: 5639146
7. World Health Organization, (2014) Noncommunicable Diseases Country Profiles 2014, WHO Library Cataloguing-in-Publication Data, Geneva, Switzerland.

Research reports

1. Banshu, M. & Fomboh, N. (2018) The Prevalence Of High Blood Pressure (Hypertension) And Its Associated Risk Factors In Ndu Health District, North -West Region, Cameroon.
2. Tsabang N (2016) An Ethno Pharmacological New Strategy for Discovery of Potential Antihypertensive Plants in Cameroon. Pharm: Tsabang N, Center for Research on Medicinal Plants and Traditional Medicine, Institute of Medical Research and Medicinal Plants Studies

Webography

1. https://www.hsd-fmsb.org/index.php/hsd/article/view/2890
2. https://www.walshmedicalmedia.com/open-access/an-ethno-pharmacological-new-strategy-for-discovery-of-potential-antihypertensive-plants-in-cameroon-2153-2435-1000517.pdf
3. https://www.enago.com/academy/thesis-vs-dissertation/
4. https://en.wikipedia.org/wiki/Critical_medical_anthropology
5. https://en.wikipedia.org/wiki/Ethnomethodology
6. https://www.ahajournals.org/doi/pdf/10.1161/HYPERTENSIONAHA.120.15026
7. Critical Medical Anthropology | Merrill Singer, Hans Baer | Taylor & F (taylorfrancis.com)