Patricia McInerney

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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!

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