This paper concludes that ‘The majority of prehospital clinical guidance from SSA provides clinicians with excellent ready to use end-user material’. Citation, abstract and a comment from me below.

CITATION: Afr J Emerg Med. 2020 Sep 28. doi: 10.1016/j.afjem.2020.08.005.
Guidance we can trust? The status and quality of prehospital clinical guidance in sub-Saharan Africa: A scoping review.
Malherbe P(1), Smit P(2), Sharma K(3), McCaul M(4).
Full text:

INTRODUCTION: Prehospital care is integral in addressing sub-Saharan Africa’s (SSA) high injury and illness burden. Consequently, robust, high-quality prehospital guidance documents are needed to inform care. These guidance documents include, but are not limited to, clinical practice guidelines (CPGs), protocols and algorithms that are contextually appropriate for SSA. However, SSA prehospital guidance mostly originates from the ‘Global North,’ with limited guidance for Africa by Africans. To strengthen prehospital clinical practice in SSA, we described and appraised all prehospital SSA guidance documents informing clinical decision making.

METHODS: We conducted a scoping review of prehospital-relevant guidance documents, including CPGs, algorithms, protocols and position statements originating from SSA. We performed a comprehensive literature search in various databases (PUBMED and SCOPUS), guideline clearing houses (Scottish Intercollegiate Guidelines Network, Trip, and Guidelines International Network), journals, various forms of grey literature and contacted experts. Guidance document screening and data extraction was done independently, in duplicate and reviewed by a third author. Guidance quality was then determined using the AGREE II tool and data were analysed using simple descriptive statistics.

RESULTS: We included 51 guidance documents from 13 countries across SSA after screening 2320 potential documents. The majority of guidance documents lacked an evidence foundation, made recommendations based on expert input, and were predominantly end-user presentations such as algorithms or protocols. Overall, reporting quality was poor, specifically for critical domains such as rigour of development; however, clarity of presentation was generally strong. Guidance topics were focused around resuscitation and common diseases (both communicable and non-communicable) with major gaps identified across a variety of topics; such as mental health for example.

CONCLUSION: The majority of prehospital clinical guidance from SSA provides clinicians with excellent ready to use end-user material. Conversely, most of the guidance documents lack an appropriate evidence foundation and fail to transparently report the guidance development process, highlighting the need to strengthen and build guideline development capacity to promote the transition from eminence-based to evidence-based guidance for prehospital care in SSA. Guideline developers, professional societies and publishers need to be aware of international and local guidance document development and reporting standards in order to produce guidance we can trust.

COMMENT (NPW): The conclusion of this paper contrasts with previous observations such as ‘clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease’ [], or that ‘Globally, most prescribers receive most of their prescribing information from the pharmaceutical industry and in many countries this is the only information they receive.’ [World Medicines Report, WHO]. It also contrasts with HIFA’s review in 2009, which found that ‘Health care workers in developing countries continue to lack access to basic, practical information to enable them to deliver safe, effective care’. []. In April this year, HIFA published our first systematic review which sid that information for primary health workers is ‘sometimes out of date and health workers reported being confused which to use’ … ‘Studies indicated a lack of up-to-date and relevant medicine information in low and lower middle-income settings.’ [How primary healthcare workers obtain information during consultations to aid safe prescribing in low-income and lower middle-income countries: a systematic review.]

So what is the real picture? We need real-world evidence to show whether health workers have increasing acccess to the reliable, relevant information they need, and that they are able to differentiate this from inaccurate or irrelevant information. One way to help determine this would be to update and expand the reviews done by HIFA. Another way forward would be to collect the testimony of HIFA members, especially those of you who work as clinicians across Africa. I would be interested to hear your observations, comments and suggestions.

Lastly I would like to mention the Practical Approach to Care Kit, which has been discussed enthusiastically on HIFA in recent years. PACK provides ‘a comprehensive, evidence-informed approach to clinical care that supports primary care improvement initiatives in South Africa and has been localised for several large LMICs’.

Best wishes, Neil

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