Medical education in sub-Saharan Africa: a literature review

Medical Education 2011: 45 : 973–986 Objectives This review synthesises research published in the traditional and ‘grey’ literature to promote a broader understanding of the history and current status of medical education in sub‐Saharan Africa (SSA). Methods We performed an extensive review and analysis of existing literature on medical education in SSA. Relevant literature was identified through searches of five traditional medical databases and three non‐traditional or grey literature databases featuring many African journals not indexed by the traditional databases. We focused our inquiry upon three themes of importance to educators and policymakers: innovation; capacity building, and workforce retention. Results Despite the tremendous heterogeneity of languages and institutions in the region, the available literature is published predominantly in English in journals based in South Africa, the UK and the USA. In addition, first authors usually come from those countries. Several topics are thoroughly described in this literature: (i) human resources planning priorities; (ii) curricular innovations such as problem‐based and community‐based learning, and (iii) the ‘brain drain’ and internal drain. Other important topics are largely neglected, including: (i) solution implementation; (ii) programme outcomes, and (iii) the development of medical education as a specialised field of inquiry. Conclusions Medical education in SSA has undergone dramatic changes over the last 50 years, which are recorded within both the traditionally indexed literature and the non‐traditional, grey literature. Greater diversity in perspectives and experiences in medical education, as well as focused inquiry into neglected topics, is needed to advance medical education in the region. Lessons learned from this review may be relevant to other regions afflicted by doctor shortages and inequities in health care resulting from inadequate capacity in medical education; the findings from this study might be used to inform specific efforts to address these issues.     

United States aid policy and induced abortion in sub-Saharan Africa

Objective

To determine whether the Mexico City Policy, a United States government policy that prohibits funding to nongovernmental organizations performing or promoting abortion, was associated with the induced abortion rate in sub-Saharan Africa.

Methods

Women in 20 African countries who had induced abortions between 1994 and 2008 were identified in Demographic and Health Surveys. A country’s exposure to the Mexico City Policy was considered high (or low) if its per capita assistance from the United States for family planning and reproductive health was above (or below) the median among study countries before the policy’s reinstatement in 2001. Using logistic regression and a difference-in-difference design, the authors estimated the differential change in the odds of having an induced abortion among women in high exposure countries relative to low exposure countries when the policy was reinstated.

Findings

The study included 261 116 women aged 15 to 44 years. A comparison of 1994–2000 with 2001–2008 revealed an adjusted odds ratio for induced abortion of 2.55 for high-exposure countries versus low-exposure countries under the policy (95% confidence interval, CI: 1.76–3.71). There was a relative decline in the use of modern contraceptives in the high-exposure countries over the same time period.

Conclusion

The induced abortion rate in sub-Saharan Africa rose in high-exposure countries relative to low-exposure countries when the Mexico City Policy was reintroduced. Reduced financial support for family planning may have led women to substitute abortion for contraception. Regardless of one’s views about abortion, the findings may have important implications for public policies governing abortion.     

Enhancing global control of alcohol to reduce unsafe sex and HIV in sub-Saharan Africa

Sub-Saharan Africa carries a massive dual burden of HIV and alcohol disease, and these pandemics are inextricably linked. Physiological and behavioural research indicates that alcohol independently affects decision-making concerning sex, and skills for negotiating condoms and their correct use. More than 20 studies in Africa have reported higher occurrence of HIV among people with problem drinking; a finding strongly consistent across studies and similar among women and men. Conflation of HIV and alcohol disease in these setting is not surprising given patterns of heavy-episodic drinking and that drinking contexts are often coterminous with opportunities for sexual encounters. HIV and alcohol also share common ground with sexual violence. Both perpetrators and victims of sexual violence have a high likelihood of having drunk alcohol prior to the incident, as with most forms of violence and injury in sub-Saharan Africa. Reducing alcohol harms necessitates multi-level interventions and should be considered a key component of structural interventions to alleviate the burden of HIV and sexual violence. Brief interventions for people with problem drinking (an important component of primary health care), must incorporate specific discussion of links between alcohol and unsafe sex, and consequences thereof. Interventions to reduce alcohol harm among HIV-infected persons are also an important element in positive-prevention initiatives. Most importantly, implementation of known effective interventions could alleviate a large portion of the alcohol-attributable burden of disease, including its effects on unsafe sex, unintended pregnancy and HIV transmission.     

Induced abortion in sub-Saharan Africa: what we do and do not know

The first step in addressing the growing public health problem of abortion in sub-Saharan Africa is to gain a better understanding of the problem and its complexities. Abortion behavior is inextricably connected with issues of women's roles and opportunities, and until the various dimensions of abortion behavior and its socioeconomic context are understood, governments will have difficulty addressing the problem effectively. In addition, abortion needs to be studied within the broader framework of reproductive health. In a continent where fertility is highly valued and infertility prevalent, the interaction between abortion, practice of contraception, and fears of infertility must be fully understood if we are to have any hope of reducing the numbers of unwanted pregnancies and the morbidity and mortality caused by induced abortion.     

Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis

ObjectiveTo estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa.MethodsWe systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model.FindingsWe identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9–20.4; 50 datapoints; 462 151 households; I² = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2–10.3; 84 datapoints; 795 355 households; I² = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher.ConclusionAlthough data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.     

The epidemiology of infertility: a review with particular reference to sub-Saharan Africa

The problem of infertility, with particular reference to Africa south of the Sahara, is reviewed. In many areas, up to 40% of women are reported to have completed their reproductive years without bearing a child. The condition is widely distributed, but also often localized in pockets corresponding to geographical or tribal units. Most available demographic data provide estimates of childlessness but it is not sufficient to define the problem in terms of primary and secondary infertility, pregnancy wastage, and infant and child mortality. The major underlying cause for the high levels of infertility appears to be the sequelae of Neisseria gonorrhoeae infection in both men and women, manifested as obstructive azoospermia and tubal occlusion. Other infections, such as those that may follow abortion or delivery, or systemic infections, may be important in some areas. The available data suggest that different patterns of infertility and pregnancy wastage, and different etiological agents and processes, contribute to the problem of infertility in the different areas. The need for a systematic, standardized research approach in several areas is clearly indicated.     

Occupational tuberculosis in healthcare workers in sub-Saharan Africa: A systematic review

ABSTRACT

This article investigates the incidence, prevalence and factors associated with occupational tuberculosis (TB) in healthcare workers (HCWs) in sub-Saharan Africa (SSA). Studies were extracted from MEDLINE, PsycINFO, CINAHL, Cochrane Library, and SCOPUS databases following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement from inception to the 2^nd of June 2017. Twenty-one studies met the inclusion criteria. The median prevalence of latent TB infection in HCWS was 62% (IQR 22%) and the median incidence of TB disease was 3871/100,000 (IQR 9314/100,000). The risk factors associated with LTBI or active TB disease were workplace, history of contact with TB patients, and longer duration of employment. The findings of this review demonstrate that the risk of acquiring TB among HCWs in SSA is high. This may impact on the recruitment, longevity and retention of HCWs.     

Global consequences of unsafe abortion

Unsafe abortion is a significant cause of death and ill health in women in the developing world. A substantial body of research on these consequences exists, although studies are of variable quality. However, unsafe abortion has a number of other significant consequences that are much less widely recognized. These include the economic consequences, the immediate costs of providing medical care for abortion-related complications, the costs of medical care for longer-term health consequences, lost productivity to the country, the impact on families and the community, and the social consequences that affect women and families. This article will review the scientific evidence on the consequences of unsafe abortion, highlight gaps in the evidence base, suggest areas where future research efforts are needed, and speculate on the future situation regarding consequences and evidence over the next 5-10 years. The information provided is useful and timely given the current heightened interest in the issue of unsafe abortion, growing from the recent focus of national and international agencies on reducing maternal mortality by 75% by 2015 (as one of the Millennium Development Goals established in 2000).     

Injection drug use, unsafe medical injections, and HIV in Africa: a systematic review

The reuse of injecting equipment in clinical settings is well documented in Africa and appears to play a substantial role in generalized HIV epidemics. The U.S. and the WHO have begun to support large scale injection safety interventions, increased professional education and training programs, and the development and wider dissemination of infection control guidelines. Several African governments have also taken steps to control injecting equipment, including banning syringes that can be reused.     

Heart failure in sub-Saharan Africa: a literature review with emphasis on individuals with diabetes

Purpose

Heart failure is the ultimate complication of cardiac involvements in diabetes. The purpose of this review was to summarize current literature on heart failure among people with diabetes mellitus in sub-Saharan Africa (SSA).

Method

Bibliographic search of published data on heart failure and diabetes in sub-Saharan Africa over the past 26 years.

Results

Heart failure remains largely unexplored in general population and among people with diabetes in Africa. Heart failure accounts for over 30% of hospital admission in specialized cardiovascular units and 3%–7% in general internal medicine. Over 11% of adults with heart failure have diabetes. Risk factors for heart failure among those with diabetes include classical cardiovascular risk factors, without evidence of diabetes distinctiveness for other predictors common in Africa. Prevention, management, and outcomes of heart failure are less well known; recent data suggest improvement in the management of risk factors in clinical settings.

Conclusions

Diabetes mellitus is growing in SSA. Related cardiovascular diseases are emerging as potential health problem. Heart failure as cardiovascular complication remains largely unexplored. Efforts are needed through research to improve our knowledge of heart failure at large in Africa. Multilevel preventive measures, building on evidences from other parts of the world must go along side.     

Prevalences of dementia and cognitive impairment among older people in sub-Saharan Africa: a systematic review

Objective

To perform a systematic review of the literature on the prevalence of cognitive impairment and dementia in sub-Saharan Africa.

Methods

Five electronic databases were searched for relevant abstracts and to identify papers eligible for full-text review. A study was included if two authors agreed that it had a cohort, case–control or cross-sectional design and reported population-level data; was limited to black African adults older than 50 years or described as “elderly” or “old”; reported data for individuals residing in sub-Saharan Africa; and reported at least one measure of cognitive impairment or clinical outcomes relevant to cognitive decline. References of papers included in our study were searched to identify additional candidate publications. Disagreements about inclusion were adjudicated during discussions involving all authors. Data were extracted independently by two authors, using a form developed by the authors and tested on a sample of papers.

Findings

A total of 2320 unique papers was found; the full text of 87 was reviewed. Nineteen papers featuring 11 cross-sectional studies were included; all were published during 1995–2011. Studies occurred in Benin, Botswana, the Central African Republic, the Congo and Nigeria and enrolled approximately 10 500 participants. The prevalence of dementia ranged from 0%, in Nigeria, to 10.1% (95% confidence interval, CI: 8.6–11.8), also in Nigeria. The prevalence of cognitive impairment ranged from 6.3%, in Nigeria, to 25% (95% CI: 21.2–29.0), in the Central African Republic.

Conclusion

Prevalences of dementia and cognitive impairment in sub-Saharan Africa varied widely, with few published studies revealed by the literature search.     

Condoms in sub-Saharan Africa

Sub-Saharan Africa (SSA) is the region with the world's highest rates of HIV and other sexually transmissible infections (STIs), yet numerous studies show that condom use is generally rare. This suggests a need for a better understanding of how condoms fit within sexual practices and relationships in SSA. This paper seeks to address this need by reviewing research published between the late 1980s and 2011 on use and factors influencing use of male condoms in SSA. What is evident from this research is that condom use involves complex social and interpersonal dynamics, with structural and cultural conditions exerting an influence through framing social cognitions and setting boundaries on autonomy that make the apparently irrational choice of eschewing condoms a rational decision. The influences of poverty; relationships with parents, peers and partners; limited, insufficient or absent information especially in rural areas and among men who have sex with men; gender and sexual norms, and the dynamics of gendered power; and beliefs and attitudes about HIV, condoms and sexuality all have been shown to work against condom use for a large proportion of Africa's people. However, promising results are shown in trends towards increased condom use among single women in numerous countries, increasing acceptance and use of condoms among some university students, successes in producing potentially sustainable condom use resulting from select interventions, and resistance to succumbing to the dominant gender-power dynamics and structural-cultural impediments that women in groups have mobilised.     

Uptake of permanent contraception among women in sub-Saharan Africa: a literature review of barriers and facilitators

Objective

Uptake of permanent contraception among women remains low in sub-Saharan Africa compared to other regions. We aimed to synthesize available evidence on barriers to, and facilitators of permanent contraception with regards to tubal ligation among women in sub-Saharan Africa.

Noma: a neglected scourge of children in sub-Saharan Africa.

Poverty is the single most important risk indicator for noma (cancrum oris), a severe gangrene of the soft and hard tissues of the mouth, face, and neighbouring areas. The risk factors associated with an increased probability of noma developing include the following: malnutrition, poor oral hygiene, and a state of debilitation resulting from human immunodeficiency virus (HIV) infection, measles, and other childhood diseases prevalent in the tropics. There are many similarities between noma and necrobacillosis of the body surface of wallabies (Macropus reforgriseus), and it is proposed that noma results from oral contamination by a heavy load of Bacteroidaceae (particularly Fusobacterium necrophorum) and a consortium of other microorganisms. These opportunistic pathogens invade oral tissues whose defences are weakened by malnutrition, acute necrotizing gingivitis, debilitating conditions, trauma, and other oral mucosal ulcers. The current escalation in the incidence of noma in Africa can be attributed to the worsening economic crisis in the region, which has adversely affected the health and well-being of children through deteriorating sanitation, declining nutritional status and the associated immunosuppression, and increased exposure to infectious diseases. Prevention of noma in Africa will require measures that address these problems, and most importantly, eliminate faecal contamination of foods and water supplies.     

An overlooked priority: puberty in sub-Saharan Africa

Early adolescence remains an overlooked window of opportunity for public health intervention with girls and boys in sub-Saharan Africa. Minimal health data exist on pubescent girls and boys. Considerable morbidity and mortality related to HIV, sexually transmitted infections, and pregnancy emerge soon after puberty, suggesting the importance of targeting early adolescents. The fundamental goal of primary prevention would be better served if girls and boys between the ages of 10 and 14 years were targeted for effective and contextually relevant interventions. Such interventions should address healthy transitions to young adulthood to effectively advance the public health agenda with postpubescent (aged 15 to 24 years) young women and men. The global health community is overdue to build the empirical database for intervention with this age group.