When investigating the research methods, it was found that not all the articles mentioned research designs. However, more quantitative findings (62% n = 31) were presented as opposed to qualitative findings (32%; n = 16). Similar to the research designs, sampling methods were missing from some of the studies. Convenience sampling was the most popular sampling method (28%; n = 14), and only 6 (17.6%) of the 34 studies with a quantitative component used a calculated sample size. Not all the work mentioned the sample size, but sample sizes ranged between 1 and 980. The sample size of the qualitative work ranged from 6 to 82, with an average of 19.4 and median of 15. The sample sizes of the quantitative work ranged from 22 to 980, with an average of 253.8 and median of 261. Interviews (72%; n = 36) collected most of the data, and questionnaires (46%; n = 23) were the most commonly used data-gathering instrument. The research designs and methods are outlined in Table 5.
Only 12 of the studies (24%) were funded; 7 (14%) were funded by the Tshwane University of Technology, South Africa, and 2 (4%) by the National Council for Science and Technology, Kenya; the Cancer Association of South Africa, the Institutional Collaboration Training Project, Zambia, and the Swedish Children’s Cancer Foundation in combination with the University of West England each funded 1 study.
Most of the studies (96%; n = 48) did not meet the criteria of high-quality work (Table 6). The quantitative work mostly lacked calculated sample sizes, and only 1 study (2%) had comparison groups. However, all the studies included clearly described outcomes measures. Most (75.0%; n = 16) of the qualitative work met the criteria to be regarded as fair quality. Procedural rigor scored the lowest, whereas heuristic relevance scored the highest.
The study provided evidence of 50 studies conducted in Africa by nurses affiliated with an African institution in the field of cancer nursing from 2005 to 2014; a more than 10-fold increase since the publication of the world review published in 2006.2 In addition to the increase in publications, it was positive to find 7 countries who were not featured in the world review published some of the work included in the current review. Unfortunately, we lost 1 country since the world review as we could not find evidence of any publication originating from this specific country. Most of the work originated from South Africa, which is not unique in the African context. Adejumo and Lekalakala-Mokgele28 when describing the studies concerning nursing in Africa from 1986 to 2006, as well as Sun and Larson1 when scoping clinical nursing and midwifery research in African countries between 2004 and 2014, found the same trend. Sun and Larson1 found 79.5% of the work included in their study originated from South Africa, whereas Adejumo and Lekalakala-Mokgele28 indicated that 67.3% of the work included in their study originated from Southern Africa particularly South Africa. Adejumo and Lekalakala-Mokgele28 explain the distribution of the work by stating that nursing education has been long established in these countries.
How the growth in publications compares to the research output of the rest of the developing world and even the developed world is unknown, and we would have to wait for an updated world review before we could draw conclusions. However, the world review included 3 developing countries outside Africa, Brazil, Iran, and Korea, which published 2 and 1 article each, respectively. When comparing African cancer nursing research output with those of nursing and midwifery research in general, cancer nursing is not high on the agenda. Topics related to primary healthcare and community health nursing, midwifery, child nursing, nursing education issues, human immunodeficiency virus and AIDS, and professional issues are the most common research focus.1,28 Sun and Larson1 found that funding was one of the major drivers of the research priorities and research topics in Africa. This would influence cancer nursing research, as Africa spends approximately 80% of the limited amount allocated to healthcare on acute communicable diseases, which have also been the overwhelming focus of donors,9 whereas cancer is not a donor priority.29
Adewole and colleagues30 identified the African environment, inadequate research infrastructure, and lack of funding and other resources as barriers to rigorous cancer research in Africa. Klopper and Uys,31 when describing the state of nursing and nursing education in Africa, highlighted various educational factors that could influence the quality of research including lack of access to higher education (where the search for external funding has become a crucial responsibility), university’s challenges in terms of shortage of faculty, lack of development, weak research and innovation capacity, brain drain, and poor facilities and infrastructure. These facors could have added to the low quality of the articles reported in the current review but cannot be the sole reasons, as Molassiotis et al2 regarded the quality of the studies in the world review, dominated by the developed world, “disappointing.” Although Africa’s nurses did not produce clinical trials, prospective studies with comparison groups, or retrospective studies with controls, the quality of both the quantitative and qualitative work did not compare poorly with what was found in the world review. However, it was noted that, similar to the findings of the world review, essential information was not reported, and inaccuracies and inconsistencies were noted in the study designs. Molassiotis and colleagues2 warn that cancer nursing would only be taken seriously by our interdisciplinary colleagues if the quality of our work was of high standard. Africa’s nurses might face an additional challenge as Imbayarwo, a Zimbabwean scientist, stated, “Anything from Africa has always been looked down upon.”32
It was positive to find that most of the work was cited, even if not published in journals with an impact factor. To urge Africa’s cancer nurses to publish only in journals with impact factors, which leads to a significantly higher citation rate, might not be reasonable. It might be more appropriate for Africa’s cancer nursing scholars to conduct focused research and build a body of knowledge to inform cancer nursing science and practice on the continent instead of striving to publish a few articles with high citation rates. This, however, does not mean that quality could be compromised. Imbayarwo is of the opinion that Africa’s researchers do not publish work in local journals because it is of a low standard, but because of the subject matter and time pressures.32 Also, Adejumo and Lekalakala-Mokgele28 related the increase in Africa’s nursing publications to the presence of nursing journals based in Africa. However, the visibility and availability of the work published in some of these journals are hindered by limited access, not only to full texts but also titles and abstracts of the work. Fortunately, during the period of the review, 2 of the African-based journals have changed to an open-access system, and Africa welcomed a new open-access international nursing journal focusing on nursing and midwifery in general. It would be interesting to see how the improved visibility and availability would influence the number of citations as well as the quality and quantity of cancer nursing publications.
What is of great concern is that Africa lacks a dedicated cadre of cancer nursing researchers as most of the authors contributed to only 1 article. Without dedicated cancer nurse researchers, we would not be able to move away from collecting baseline data and conduct more sophisticated research to build a body of knowledge to inform African cancer nursing science and practice and improve outcomes in terms of the prevention and early detection of cancer and the outcomes of patients, caregivers, and families living with cancer. The reasons for this situation are not clear; however, it seems as if the shortage of faculty at Africa’s universities forces faculty to supervise postgraduate students across nursing fields, hindering them from building and focusing on their specialist field. For instance, van Rooyen et al33 found that only 4 of the 105 doctor of philosophy degree–prepared nursing faculty at South African universities held a National Research Foundation rating that calls for scholarly work with a definite research focus. It might also be possible that some of the authors were not interested in research, but conducted research because it was required of them28,34 and therefore did not continue their work. This is, however, mere possibility and should be investigated to draw definite conclusions. In addition, it seems as if nurses practicing in cancer care settings do not conduct research, as only 3 of the African authors were not affiliated with an academic institution. Roxburgh,35 in a study conducted in Scotland, found that clinical nurses were generally receptive to conducting research but were challenged by their knowledge and skills to conduct research, which, bearing in mind the educational challenges of nurses in Africa, might also be applicable to the African setting.
As seen in Figure 2, the research conducted is inconsistent to the cancer profile of Africa. Cervical cancer and breast cancer received the most attention, and other prevalent cancers such as liver cancer, prostate cancer, non-Hodgkin lymphoma, colon and rectum cancer, esophageal cancer, Kaposi sarcoma, and lung, stomach, and bladder cancers were not investigated.36 In addition, work focusing on the patient with cancer, symptoms, treatment-related issues, and supportive care lacks foundation. Whether the lack of diagnostic and treatment opportunities faced by Africa’s cancer patients played a role in this deficit is quite possible. Considering the lack of infrastructure, high disease burden, and advanced stage at presentation, it was interesting to find that palliative care received so little attention. In addition, patients living with pain and pain management were not investigated, which is a serious gap in our research as pain is a major problem for people living with cancer in Africa, while morphine is either not available or not accessible in most African countries.37,38 It was also interesting to find that the family, caregiver, and the community living with people with cancer were not included in the work presented in this review. Researching these topics is especially important because in most of Africa, the philosophy of interconnectedness, called Ubuntu in South Africa (“I am because you are”), the family, extended family, and community, plays an important role in the life of a person.
Most of the work (62%) used a quantitative approach, whereas mixed-methods and case studies produced single articles. Molassiotis et al,2 in the world review of cancer nursing research outputs, found a similar trend, with 60.2% of the articles quantitative, which is supported by Adejumo and Lekalakala-Mokgele,28 who found that 64.3% of the general nursing research output of Africa was quantitative. This is in contrast with the study of Sun and Larson,1 who found the opposite with 41.1% of the work being quantitative. Whether this is positive or negative is debatable. The advantages of qualitative research are well known, and it is also well known that qualitative and quantitative methods can complement each other and can be used sequentially or in tandem. However, one of the major advantages of qualitative research is the fact that it gives voice to the voiceless,39 which would be an important starting point when we advocate for affordable accessible screening opportunities, diagnostic facilities, affordable treatment, and the availability of essential palliative drugs such as morphine. It comes as no surprise that interviews were the most commonly used method for data collection, as 40% of Africa’s population are still unable to read and write.40
The majority of the work included in the current review collected data from people living in the community. This is a positive trend and in constrast to the work presented in the world review,2 where most of the studies focused on nurses and other healthcare professionals. In addition, focusing on cancer prevention is the appropriate approach for Africa’s cancer nurses and adhered to “the 10 priorities and actions for cancer research and control in Africa.”36(p248) Sylla and Wild36 support the prioritization of research on the causes of cancer and cancer prevention, promotion of primary prevention, introduction of screening and early detection, access to basic diagnostic services and affordable treatment, and international collaborations. This calls for more sophisticated work than exploring and describing some knowledge aspect of cancer and should include intervention studies allowing us to develop, test, and refine ways to prevent cancer; mobilize people to make use of screening opportunities; provide cancer screening opportunities; establish basic diagnostic services; and advocate for affordable treatment and essential palliative drugs. International collaboration is indeed needed to strengthen these attempts. Considering the challenges we face and the information we most commonly obtained from participants, it is quite reasonable to conclude that the field knowledge, attitudes, and practices have reached maturity and would only call for additional work in extraordinary circumstances.
Our study has various limitations. It is unlikely this review presented the total body of work done in Africa by nurses affiliated to an African institution in the field of cancer nursing, as we focused on peer-reviewed literature available by means of selected databases. In addition, we acknowledge that some articles meeting the inclusion criteria could have been missed because of the uncertainty whether the authors were nurses affiliated with an African institution.The key words selected for the study and including only the individual countries in possession of radiotherapy machines in addition to “Africa” could also be limitations. Using the term “nursing” could have resulted in not including multidisciplinary work in which nurses participated. Furthermore, the number of citations was assessed 6 months after the end of the review cycle, which could have influenced the number of citations positively. Yet, the researchers believe that the work included in this review provides a good representation of the work done in the field of cancer nursing in Africa by Africa’s nurses from 2005 to 2014. It would be helpful for future reviews if authors could indicate their nursing status by adding a recognizable acronym, such as RN, to their names.
Africa’s nurses have improved their research output in the field of cancer nursing significantly and should celebrate this achievement. In addition, we added to the body of knowledge in terms of primary and secondary cancer prevention; however, the field of knowledge, attitudes, and practices has now definitely reached maturity. Research focusing on the most prevalent cancers, the treatment, the patient living with cancer, the family, extended family, and community is lacking, as is work focusing on palliative care and pain and other symptoms. There is an urgent need for multidisciplinary innovative and influential collaborative work to improve the availability of screening opportunities, improve screening uptake, and improve cancer outcomes throughout the trajectory of the disease.
Implications for Nursing Practice
Africa’s nurses practicing in disease prevention, cancer care, primary healthcare, and palliative care should join forces with nurse researchers to address the identified knowledge gaps, which would assist with the development of cancer nursing science and practice tailored to meet the unique needs of Africa.
The authors thank Mr C. Maree for his assistance with the database searches.
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Keywords:Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved
Africa; Integrative review; Nursing research output