We conducted a prospective cross-sectional study between December 2018 and July 2019 (6 months) at two major cardiology and internal medicine departments of Yaoundé, Cameroon’s political capital. These were the cardiology department of Yaoundé Central Hospital (YCH). The YCH, located in the district of Yaoundé 2, is a central-level hospital equipped with several units, including one of medicine and Specialties and an imaging department or additional examinations such as electrocardiography (ECG) echocardiography can be performed with a capacity of 650 beds in the hole hospital and 32 beds in the cardiology department. Using consecutive convenient sampling, we recruited all consenting patients aged ≥ 18 with HF confirmed based on Framingham criteria during the study period [14] .

After obtaining ethical clearance from the Institutional Review Board of the “Université des Montagnes” and research authorisation from the different the two hospitals included in the study: 1) we identified during outpatient consultations the patients meeting the various eligibility criteria; 2) then, we explained to the patients the purpose, importance and modalities of the conduct of the study and obtain their informed consent; 3) the participants were subjected to a questionnaire pretested and prevalidated, with the help of a language translator allowing information to be collected on socio-demographic data (age, sex, profession, level of education, ethnicity, religion, marital status), personal history (the circumstances of discovery of HF, initial symptoms such as dyspnoea, weight gain, oedema of the lower limbs, fatigue), consultation characteristics (the time elapsed between the onset of symptoms and the first medical consultation), the different types of care structure (district hospitals, regional hospitals, central hospitals and general hospitals), types of treatment (complementary and alternative medicine, auto-medication, religious, abstention from treatment), the patient’s motivations for going to a facility, the interventions in each resort, the duration of treatment at each treatment station (the time spent in each treatment station from consultation to discharge), the time between each recourse, the clinical evolution (accentuation of clinical symptoms present at the start or reduction of clinical symptoms present at the beginning), diagnostic time (the time elapsed between the first medical consultation and the time when the diagnosis was made), total number of treatment options; 4) analysis of the data collected; 5) the interpretation of the results obtained.

The therapeutic route also called the treatment care route, is the path patients and their families take to search for health. The ideal route is a progressive referral approach between primary health care centres, usually run by state registered nurses and general practitioners, followed by secondary care hospitals like district hospitals and regional hospitals run by general practitioners and medical specialists and finally, tertiary care hospitals such as Central hospital or General Hospital. The pseudo-ideal route is one leap at most in the different stages of the health pyramid. The Erratic Route does not follow the various steps of the health pyramid. Recourse to care is a request for care addressed to people or institutions that do not always define themselves as caregivers. The consultation time is the halfway point between the onset of the initial symptoms and the first consultation in a care structure. The diagnostic delay is the time between the beginning of the initial signs and the HF diagnosis. Auto-medication is the use of drugs taken on the patient’s initiative. The natural practice is an action that we carry in a banal way, either because we are used to it or because it takes away from us (our daily life or culture). The traditional healer or therapist is an individual who exercises an unconventional medical practice based on approaches presented as standard in some African communities. Non-specific treatment is patient management that has nothing to do with heart failure.

Data entry and data analysis were done using EPI-INFO version 7.2 software. The results were expressed in terms of the mean ± standard deviation for the quantitative variables and frequency and percentage for qualitative variables. The Student’s t-test was used for normally distributed continuous variables. Nonparametric tests in case of constant variables not following a normal distribution law. P-values less than 5% were considered statistically significant.

Ethics clearance was obtained from the Institutional Ethics Committee of the Université des Montagnes (Authorization No. 2019/153/UdM /PR /CIE), followed by securing research authorisations from the head management of each study hospital. The study was carried out following the fundamental principles of medical research of the Declaration of Helsinki [4] and Good clinical practice principles.

Our population comprised 132 HF patients: 83 women (62.88%) and 49 men (37.12%). The average age of our patients was 62.90 years, with extremes ranging from 21 to 96 years. The most represented age group was 50 to 70 years old in 50.76% of cases. The majority level of education was primary (35.61%). Less than half (31.82%) had a fixed monthly income. Their average monthly income was 148,880 FCFA, equivalent to 270 US dollars, with a minimum of 30,000 FCFA, equivalent to 54 US dollars and a maximum of 450,000 FCFA, equal to 816 US dollars. The most common causes of HF were hypertension with 50%, dilated cardiomyopathy (15.15%), and valvular heart disease (12.12%). The most common comorbidity was chronic kidney disease (6.06%). The most common cardiovascular risk factors were high blood pressure 68.94%, obesity (18.94%), and diabetes (15.15%). NYHA Stage II (43.94%) and III dyspnea were the most represented (49.34%). See Table 1.

The most prescribed drug classes were diuretics (92.42%) and Angiotensin-con- verting enzyme inhibitors (ACEI)/Angiotensinogen II receptor antagonists (ARB II) (81.82%). The most prescribed molecules are respectively furosemide (93.44%) for the class of diuretics, nebivolol (52.54%) for the type of beta-blockers, perindopril (38.89%) for the class of ACEI/ARB II, digoxin (13.85%) for the digitalis class and spironolactone (14.06%) for the antialdosterone class. See Table 2.

To describe HF patients’ various steps in their different therapeutic routes, we excluded patients already followed for another cardiovascular pathology other than HF at YCH, i.e. 17 patients. The patients needed one (6.25%), two (62.25%), three (25.89%), and four resorted therapeutic routes (25.89%). Most of our patients (73.68%) resided in Yaoundé, and 70 (62.25%) resorted to two therapeutic routes. Regarding auto-medication, 48 patients (36.36%) resort to it. Modern self-medication (buying drugs from a pharmacy without a prescription by a treating staff) and complementary and alternative medication were found in 26 patients (57.78%) and 32 patients (72.73%), respectively. A statistically significant difference between the time elapsed between the first symptoms and the consultation of the first referral in patients residing in Yaoundé and those living far from Yaoundé with a p-value of 0.0033 (Table 3). Likewise, a statistically significant difference between the time elapsed between the first symptoms and the HF diagnosis in patients residing in Yaoundé and those living far from Yaoundé with a p-value of 0.003 (Table 3).

1 US dollar = 553.89 at the time of this study.

ACEI: Angiotensin-converting enzyme inhibitors, ARB II: Angiotensin II receptor blockers.

Patients residing in Yaoundé resorted to more than ten therapeutic routes (see Figure 1). Patients spend an average of 30.18 days at home before seeking treatment. The first most frequented care structures are the integrated health centre (IHC) 35.71%, 15.47% in district hospitals (DH), and 15.47% at Jamot Hospital (JH). After spending approximately 18.63 days on average in the first structure, some decided to resort to a second structure for better care, which was a specialised structure, YCH (72.72%) or JH (7.80%). See Figure 1. Half of our patients had a pseudo-ideal route, with one jump at most in the health pyramid’s different stages.

A single patient had an ideal therapeutic route therapeutic routes following all the stages of the health pyramid in our health system, i.e. home → IHC (nurse) → primary care hospital/District Hospital → CMA / DH (general practitioner) → regional hospital or HR (general practitioner, specialist) → YCH (specialist). See Table 4.

The patients residing near Yaoundé (not longer than 30 km from their homes to a place of care) mainly had five therapeutic routes (Figure 2).

Patients spend an average of 9.21 days at home before seeking treatment. The first most frequented care structures are the IHC (69.23%), the DH (23.07%), and the traditional practitioner (23.07%). After having done about 41.30 days on average in the first structure, some decided to have recourse to a second structure to have better care, which, for the most part, was a specialised structure for YCH (81.81%) or JH (18.18%). Of the 13 patients living near Yaoundé, 11 patients (84.61%) had a pseudo-ideal itinerary. See Table 5.

Patients living far away from Yaoundé (longer than 30 km from their homes to a place of care) had different routes from patients residing in Yaoundé and near Yaoundé. We have listed more than ten routes (Figure 3).

Patients spend an average of 48.66 days at home before seeking treatment. The first most frequented care structures are the IHC (42.10%), the DH (22.23%), the Regional Hospital (RH) (11.12%) and the JH (11.12%). After having done about 89.11 days on average in the first structure, some decided to have recourse to a second structure to have better care which, for the most part, was a specialised structure for YCH (61.12%) or the JH (16.67%). Of the 18 patients living far from Yaoundé, 15 patients had a pseudo-ideal itinerary (see Table 6).

Patients’ primary motivations for going to the first therapeutic resort were geographic proximity (52.57%) and advice from someone (31.82%). On the other hand, patients went to the second resort either because the symptoms persisted (44.76%) or because they had been referred by a health professional (14.28%) or because they considered that the disease was severe and therefore decided to go to a structure superior to the previous one for better management (see Table 7).

The time between the first symptoms and the first resort’s consultation was longer in the group living far from Yaoundé than in Yaoundé, with a significant difference. Likewise, we note that the time elapsed between the first symptoms and the diagnosis of HF is higher in patients with NYHA stage III-IV HF at the time of diagnosis with a statistically significant p-value of 0.0019 (see Table 8).