Evidence-based Health Care in Africa: Evidence-based Health Care in Africa Patricia McInerney
School of Nursing
University of KwaZulu-Natal, South Africa
Dare, Volmink and Clark (2005) report that: Dare, Volmink and Clark (2005) report that 75 million more Africans live in poverty today than a decade ago
Nearly half the region’s people live on $1 a day or less
Population statistics and life expectancies for some African countries: Population statistics and life expectancies for some African countries
Dare, Volmink and Clark (2005) state that : Dare, Volmink and Clark (2005) state that More than 80 million Africans will die of AIDS by 2025
Another 90 million (more than 1:10 people) on the continent will become infected
HIV/AIDS: HIV/AIDS For many Africans, by the time a diagnosis is made, the disease is already advanced and the individual has symptoms of AIDS – thus the disease is referred to as HIV/AIDS
Adult prevalence of HIV/AIDS (15-49 years) in 2003: Adult prevalence of HIV/AIDS (15-49 years) in 2003
Implications of the impact on the 15-49 year age group: Implications of the impact on the 15-49 year age group Economically active age group
Future of the country
Providers of the children and elderly
Other contributors to the low life expectancy rate: Other contributors to the low life expectancy rate Tuberculosis
Malaria
Diabetes
Hypertension
Malaria: Malaria Globally- there at least 300 million acute cases of malaria each year,
Resulting in more than one million deaths
Around 90% of these deaths occur in Africa, mostly in young children.
Malaria is Africa’s leading cause of under 5 mortality (20%)
Tuberculosis: Tuberculosis 188 695 new cases of TB were reported in SA in 2001
A number of TB sufferers are multi-drug resistant
HIV and TB: HIV and TB HIV prevalence amongst TB patients in SA varies from 12% (W Cape) to 67% (KZN)
In HIV +ve individuals the risk of developing TB is 10% / annum
In HIV –ve individuals the risk of developing TB is 10% / life time
Lack of qualified health professionals: Lack of qualified health professionals
Number of physicians /100 000 population: Number of physicians /100 000 population
What has this to do with evidence-based practice?: What has this to do with evidence-based practice?
Worldviews on Evidence-based Nursing: Worldviews on Evidence-based Nursing “evidence-based practice in nursing and midwifery is in its infancy (in South Africa.)” (McInerney 2004)
If correct – then fairly safe to say that even less is known about it in the rest of Africa.
Questionnaire given to 55 delegates attending an EBP workshop in Durban – June 2005: Questionnaire given to 55 delegates attending an EBP workshop in Durban – June 2005 44 - South Africans
3 – Batswana
2 – Nigerians
6 - Swaziland
Main focus of work: Main focus of work Nurse educator in a nursing college – 16
Nurse educator in a university – 17
Nurse educators in a private hospital – 5
Nurse practitioner in a public hospital – 1
Nurse managers – 7
Physiotherapist – 1
Pharmacist – 2
Medical Aid companies - 4
State of EBP in the workplace: State of EBP in the workplace Used in managed care
Medical aid industry
Databases mostly used are:
Cochrane
NICE
SIGN
Other comments about the use of EBP in the workplace in SA: Other comments about the use of EBP in the workplace in SA EBP is virgin territory
Where it is in place, it is more by chance than by design
Most practice is consensus based and practice is based on tradition
Only academic institutions know about it – the clinical settings are still very isolated
EBP is incidental and the evidence is usually very outdated
Respondents from Swaziland and Nigeria stated that it is taught theoretically but is not used in practice: Respondents from Swaziland and Nigeria stated that it is taught theoretically but is not used in practice
Promotion of EBP in the workplace: Promotion of EBP in the workplace 51% - not promoted in the workplace
Of the 42% who stated that it is – 4 qualified their responses by adding “by myself”; “very limited”; “at unit level”
44% - stated that they use EBP in their work
When did you first hear about EBP?: When did you first hear about EBP? The earliest time mentioned was 1998
18 were hearing about it for the first time at this workshop
3 had heard about it during their nursing studies
One - when she had worked abroad
How is EBP promoted in the workplace?: How is EBP promoted in the workplace? Medical aid industry – the decision to fund is based on clinical evidence and policies
Policies and procedure manuals – 7
One stated that policies are reviewed with EBP in mind and the research findings are included in the policy guideline
Two made reference to Cochrane and one to using nursing sensitive quality indicators
Sources of information: Sources of information For the 44% who used EBP in their work, the following sources of information were mentioned:
Cochrane (12=50%)
JBI (1)
Colleagues (17=71%)
Expert opinion (18=75%)
Other sources of information mentioned were: scientific literature Internet NICE guidelines Texas guidelines IRISH NHS Health : Other sources of information mentioned were: scientific literature Internet NICE guidelines Texas guidelines IRISH NHS Health
Is there a place for EBP in Africa?: Is there a place for EBP in Africa? 96% felt that it is possible to implement EBP in Africa
Only two felt that it is not – one of these respondents was from Swaziland
Obstacles to implementing EBP in Africa: Obstacles to implementing EBP in Africa Lack of resources
Computers and access to the internet (27%) and 7 (13%) mentioned the lack of computer literacy and reluctance to use the internet
Financial (22%)
Slide31: Management issues (27%) – “culture of retrospective analysis” and lack of accountability
Resistance to change (22%) – getting health professionals to move away from old methods
Slide32: “African factors”
Lack of evidence in Africa
Lack of country specific data to effect change
Western influence
Limited amount of clinically-based research (from Africa)
Challenges to implementing EBP in Africa: Challenges to implementing EBP in Africa Overcoming the resistance to change (24%)
Providing the infrastructure in terms of computers and computer literacy; need to educate nurses at the clinical level about EBP
Management need to persuaded to introduce the concept (11%)
Issues related to cost and finance
Suggestions made to overcoming obstacles: Suggestions made to overcoming obstacles Need for more knowledge and workshops (29%)
Emphasis in basic education on EBP; at higher degree level on systematic reviews
All stakeholders to work together – public / private interface
Resources be made available in terms of computers, computer literacy and development of personnel to undertake systematic reviews
Understanding of EBP: Understanding of EBP
Almost all (80%) of the respondents stated that their understanding of EBP had changed after the workshop: Almost all (80%) of the respondents stated that their understanding of EBP had changed after the workshop
Ways in which understanding had changed: Ways in which understanding had changed EBP is based on research – not fundamental consensus
Learnt how systematic reviews are done
Difference between opinions, experience and systematic reviews was commented on more than once
Better understanding of how level of evidence impacts on guidelines / how internet searches can give very inappropriate information
Slide38: Understand the difference between Cochrane and JBI
All the research has been done – so not based in individual preferences
Management of knowledge and context in clinical practice – does not add work, it may reduce work!
Where to from here?: Where to from here? Is there truly a place for evidence-based care in Africa?
I believe that there is! : I believe that there is!
Recommendations from JBI Best Practice Sheets: Recommendations from JBI Best Practice Sheets
BPS – Impact of preoperative hair removal on surgical site infection: BPS – Impact of preoperative hair removal on surgical site infection Shaving versus no hair removal – surgery without hair removal is preferable to preoperative hair removal with a razor blade to prevent surgical site infection (category 1B)
Shaving versus clipping – clipping is the preferred method of hair removal to prevent surgical site infection (category 1A)
BPS – management of nipple pain and/or trauma associated with breastfeeding: BPS – management of nipple pain and/or trauma associated with breastfeeding Interventions aimed at preventing nipple pain / trauma
Warm water compresses are recommended for the prevention of nipple pain
Keep nipples clean and dry to prevent cracked nipples
Slide44: Interventions aimed at treating nipple pain/trauma
Warm water compresses are recommended for the reduction of nipple pain
Breastmilk massaged onto the nipple post feeding reduces the duration of cracked nipples
BPS – solutions, techniques and pressure in wound cleansing: BPS – solutions, techniques and pressure in wound cleansing Solutions for wounds
For adults with lacerations, tap water is an effective cleansing solution (level III,1)
Tap water is effective to cleanse clean sutured surgical wounds in healthy adults (level III,1)
Boiled and cooled water is a viable alternative as wound cleansing solution in the absence of normal saline or potable tap water (level II)
Slide46: Technique for wound cleansing
Showering post-operative wounds does not increase infection or slow the healing process and promotes a sense of well-being and health associated with cleanliness (Level 1)
BPS – pelvic floor muscle exercise and urinary incontinence following childbirth: BPS – pelvic floor muscle exercise and urinary incontinence following childbirth Ensure that women are performing PFME correctly (Grade A)
Encourage women to undertake both antenatal and postnatal PFME (Grade A)
Pay particular attention to women with antenatal and postnatal urinary incontinence in providing advice and PFME instruction (Grade A)
Include PFME as a specific programme in all antenatal and postnatal care (Grade A)
Health Expenditures: Health Expenditures
Given these health expenditures and the evidence described above there is a place for EBP in Africa AND it needs to be promoted as a matter of urgency!: Given these health expenditures and the evidence described above there is a place for EBP in Africa AND it needs to be promoted as a matter of urgency!